You're viewing Docket Item 1 from the case Tom Thomas. View the full docket and case details.

Download this document:




Case 12-61259-mgd Doc 1 Filed 04/30/12 Entered 04/30/12 19:11:58 Desc Main

B1 (Official Form 1) (12/11)

Document Page 1 of 47

United States Bankruptcy Court
Northern District of Georgia

Voluntary Petition

Name of Debtor (if individual, enter Last, First, Middle):
Thomas, Tom
All Other Names used by the Debtor in the last 8 years
(include married, maiden, and trade names):
aka Tom Thomas, IV

Name of Joint Debtor (Spouse) (Last, First, Middle):

All Other Names used by the Joint Debtor in the last 8 years
(include married, maiden, and trade names):

Last four digits of Soc. Sec. or Individual-Taxpayer I.D. (ITIN) No./Complete EIN
(if more than one, state all):

7993

Last four digits of Soc. Sec. or Individual-Taxpayer I.D. (ITIN) No./Complete EIN
(if more than one, state all):

Street Address of Debtor (No. and Street, City, and State)
45 Westfield Way
Covington, GA

County of Residence or of the Principal Place of Business:
Newton
Mailing Address of Debtor (if different from street address):

ZIPCODE
30016

Street Address of Joint Debtor (No. and Street, City, and State

ZIPCODE

County of Residence or of the Principal Place of Business:

Mailing Address of Joint Debtor (if different from street address):

0

.

3

e
g
n
a
h
C
X
-
F
D
P

-


0
1
1
1
0
-
X
1
0
3
-
1
3
1
2
3

-


4
7
7
-
7

.

6

.

4


.
r
e
v


,
.
c
n
I

,
e
r
a
w

t
f
o
S

e
p
o
H
w
e
N




,



2
1
0
2
-
1
9
9
1
©
2
1
0
2
y
c
t
p
u
r
k
n
a
B

Location of Principal Assets of Business Debtor (if different from street address above):

ZIPCODE

ZIPCODE

ZIPCODE

Type of Debtor

(Form of Organization)

(Check one box)

Individual (includes Joint Debtors)
See Exhibit D on page 2 of this form.
Corporation (includes LLC and LLP)
Partnership
Other (If debtor is not one of the above entities,
check this box and state type of entity below.)

Chapter 15 Debtors

Country of debtor’s center of main interests:

Each country in which a foreign proceeding by,
regarding, or against debtor is pending:

Filing Fee (Check one box)

Full Filing Fee attached

Nature of Business

(Check one box)

Health Care Business
Single Asset Real Estate as defined in
11 U.S.C. § 101 (51B)
Railroad
Stockbroker
Commodity Broker
Clearing Bank
N.A.
Other

Tax-Exempt Entity

(Check box, if applicable)

Debtor is a tax-exempt organization
under Title 26 of the United States
Code (the Internal Revenue Code)

Chapter of Bankruptcy Code Under Which

Chapter 7
Chapter 9
Chapter 11
Chapter 12
Chapter 13

the Petition is Filed (Check one box)
Chapter 15 Petition for
Recognition of a Foreign
Main Proceeding
Chapter 15 Petition for
Recognition of a Foreign
Nonmain Proceeding

Nature of Debts
(Check one box)

Debts are primarily consumer
debts, defined in 11 U.S.C.
§101(8) as "incurred by an
individual primarily for a
personal, family, or
household purpose."

Debts are
primarily
business debts.

Check one box:

Chapter 11 Debtors

Debtor is a small business as defined in 11 U.S.C. § 101(51D)
Debtor is not a small business as defined in 11 U.S.C. § 101(51D)

Filing Fee to be paid in installments (applicable to individuals only) Must attach
signed application for the court's consideration certifying that the debtor is unable
to pay fee except in installments. Rule 1006(b). See Official Form 3A.

Filing Fee waiver requested (applicable to chapter 7 individuals only). Must
attach signed application for the court’s consideration. See Official Form 3B.

Check if:

Debtor’s aggregate noncontingent liquidated debts (excluding debts owed to
insiders or affiliates) are less than $2,343,300 (amount subject to adjustment on
4/01/13 and every three years thereafter).

Check all applicable boxes

A plan is being filed with this petition.
Acceptances of the plan were solicited prepetition from one or more
classes of creditors, in accordance with 11 U.S.C. § 1126(b).

Statistical/Administrative Information

Debtor estimates that funds will be available for distribution to unsecured creditors.
Debtor estimates that, after any exempt property is excluded and administrative expenses paid, there will be no funds available for
distribution to unsecured creditors.

Estimated Number of Creditors

THIS SPACE IS FOR
COURT USE ONLY

1-49

50-99

100-199

200-999

1,000-
5,000

5,001-
10,000

10,001-
25,000

25,001-
50,000

50,001-
100,000

Over
100,000

Estimated Assets

$0 to
$50,000

$50,001 to
$100,000

$100,001 to
$500,000

Estimated Liabilities

$500,001
to $1
million

$1,000,001
to $10
million

$10,000,001
to $50
million

$50,000,001
to $100
million

$100,000,001
to $500
million

$500,000,001
to $1 billion

More than
$1 billion

$0 to
$50,000

$50,001 to
$100,000

$100,001 to
$500,000

$500,001
to $1
million

$1,000,001
to $10
million

$10,000,001
to $50
million

$50,000,001
to $100
million

$100,000,001
to $500
million

$500,000,001
to $1 billion

More than
$1 billion

Case 12-61259-mgd Doc 1 Filed 04/30/12 Entered 04/30/12 19:11:58 Desc Main

Page 2

B1 (Official Form 1) (12/11)
Voluntary Petition
(This page must be completed and filed in every case)

Document Page 2 of 47
Name of Debtor(s):
Tom Thomas

All Prior Bankruptcy Cases Filed Within Last 8 Years (If more than two, attach additional sheet)

Location
Where Filed:

Location
Where Filed:

Northern District of Georgia

Northern District of Georgia

Case Number:

07-63854

Case Number:

10-73328

Date Filed:
3-6-07
Date Filed:
5-3-10

Pending Bankruptcy Case Filed by any Spouse, Partner or Affiliate of this Debtor (If more than one, attach additional sheet)

NONE

Name of Debtor:

District:

Exhibit A

(To be completed if debtor is required to file periodic reports (e.g., forms
10K and 10Q) with the Securities and Exchange Commission pursuant to
Section 13 or 15(d) of the Securities Exchange Act of 1934 and is requesting
relief under chapter 11)

Case Number:

Relationship:

Date Filed:

Judge:

Exhibit B

(To be completed if debtor is an individual
whose debts are primarily consumer debts)

I, the attorney for the petitioner named in the foregoing petition, declare that I
have informed the petitioner that [he or she] may proceed under chapter 7, 11,
12, or 13 of title 11, United States Code, and have explained the relief
available under each such chapter.
I further certify that I delivered to the
debtor the notice required by 11 U.S.C. § 342(b).

0

.

3

e
g
n
a
h
C
X
-
F
D
P

-


0
1
1
1
0
-
X
1
0
3
-
1
3
1
2
3

-


4
7
7
-
7

.

6

.

4


.
r
e
v


,
.
c
n
I

,
e
r
a
w

t
f
o
S

e
p
o
H
w
e
N




,



2
1
0
2
-
1
9
9
1
©
2
1
0
2
y
c
t
p
u
r
k
n
a
B

Exhibit A is attached and made a part of this petition.

X

/s/ Joseph Chad Brannen

4-30-12
Signature of Attorney for Debtor(s) Date

Does the debtor own or have possession of any property that poses or is alleged to pose a threat of imminent and identifiable harm to public health or safety?

Exhibit C

Yes, and Exhibit C is attached and made a part of this petition.

No.

(To be completed by every individual debtor. If a joint petition is filed, each spouse must complete and attach a separate Exhibit D.)

Exhibit D completed and signed by the debtor is attached and made a part of this petition.

If this is a joint petition:

Exhibit D also completed and signed by the joint debtor is attached and made a part of this petition.

Exhibit D

Information Regarding the Debtor - Venue

(Check any applicable box)

Debtor has been domiciled or has had a residence, principal place of business, or principal assets in this District for 180 days immediately
preceding the date of this petition or for a longer part of such 180 days than in any other District.

There is a bankruptcy case concerning debtor's affiliate, general partner, or partnership pending in this District.

Debtor is a debtor in a foreign proceeding and has its principal place of business or principal assets in the United Sates in this District, or
has no principal place of business or assets in the United States but is a defendant in an action or proceeding [in federal or state court] in
this District, or the interests of the parties will be served in regard to the relief sought in this District.

Certification by a Debtor Who Resides as a Tenant of Residential Property

(Check all applicable boxes)

Landlord has a judgment against the debtor for possession of debtor’s residence. (If box checked, complete the following.)

(Name of landlord that obtained judgment)

(Address of landlord)

Debtor claims that under applicable nonbankruptcy law, there are circumstances under which the debtor would be permitted to cure the
entire monetary default that gave rise to the judgment for possession, after the judgment for possession was entered, and
Debtor has included in this petition the deposit with the court of any rent that would become due during the 30-day period after the
filing of the petition.
Debtor certifies that he/she has served the Landlord with this certification. (11 U.S.C. § 362(1)).

Case 12-61259-mgd Doc 1 Filed 04/30/12 Entered 04/30/12 19:11:58 Desc Main

B1 (Official Form 1) (12/11)
Voluntary Petition
(This page must be completed and filed in every case)

Document Page 3 of 47
Name of Debtor(s):
Tom Thomas

Signatures

Page 3

Signature(s) of Debtor(s) (Individual/Joint)

Signature of a Foreign Representative

I declare under penalty of perjury that the information provided in this petition
is true and correct.
[If petitioner is an individual whose debts are primarily consumer debts and
has chosen to file under chapter 7] I am aware that I may proceed under
chapter 7, 11, 12, or 13 of title 11, United States Code, understand the relief
available under each such chapter, and choose to proceed under chapter 7.
[If no attorney represents me and no bankruptcy petition preparer signs the
petition] I have obtained and read the notice required by 11 U.S.C. § 342(b).

I request relief in accordance with the chapter of title 11, United States
Code, specified in this petition.

X

/s/ Tom Thomas
Signature of Debtor

X

X

Signature of Joint Debtor

Telephone Number (If not represented by attorney)
4-30-12
Date

Signature of Attorney*

/s/ Joseph Chad Brannen

Signature of Attorney for Debtor(s)
JOSEPH CHAD BRANNEN 077120
Printed Name of Attorney for Debtor(s)
Brannen Law Group, P.C.
Firm Name
7147 Jonesboro Road
Address
Suite G(cid:0)(cid:0)Morrow, GA 30260

770-474-0847
Telephone Number
4-30-12
Date

*In a case in which § 707(b)(4)(D) applies, this signature also constitutes a
certification that the attorney has no knowledge after an inquiry that the
information in the schedules is incorrect.

I declare under penalty of perjury that the information provided in this petition
is true and correct, that I am the foreign representative of a debtor in a foreign
proceeding, and that I am authorized to file this petition.

(Check only one box.)

I request relief in accordance with chapter 15 of title 11, United States Code.
Certified copies of the documents required by 11 U.S.C. § 1515 of title 11 are
attached.

Pursuant to 11 U.S.C.§ 1511, I request relief in accordance with the chapter of
title 11 specified in this petition. A certified copy of the order granting
recognition of the foreign main proceeding is attached.

X

(Signature of Foreign Representative)

(Printed Name of Foreign Representative)

(Date)

Signature of Non-Attorney Petition Preparer

I declare under penalty of perjury that: (1) I am a bankruptcy petition preparer
as defined in 11 U.S.C. § 110, (2) I prepared this document for compensation,
and have provided the debtor with a copy of this document and the notices and
information required under 11 U.S.C. § 110(b), 110(h), and 342(b); and, (3) if
rules or guidelines have been promulgated pursuant to 11 U.S.C. § 110(h)
setting a maximum fee for services chargeable by bankruptcy petition
preparers, I have given the debtor notice of the maximum amount before any
document for filing for a debtor or accepting any fee from the debtor, as
required in that section. Official Form 19 is attached.

Printed Name and title, if any, of Bankruptcy Petition Preparer

Social Security Number (If the bankruptcy petition preparer is not an individual,
state the Social Security number of the officer, principal, responsible person or
partner of the bankruptcy petition preparer.) (Required by 11 U.S.C. § 110.)

Address

Signature of Debtor (Corporation/Partnership)

I declare under penalty of perjury that the information provided in this petition
is true and correct, and that I have been authorized to file this petition on
behalf of the debtor.

X

The debtor requests relief in accordance with the chapter of title 11,
United States Code, specified in this petition.

X

Signature of Authorized Individual

Printed Name of Authorized Individual

Title of Authorized Individual

Date

Date
Signature of bankruptcy petition preparer or officer, principal, responsible
person, or partner whose Social Security number is provided above.
Names and Social Security numbers of all other individuals who prepared or
assisted in preparing this document unless the bankruptcy petition preparer is
not an individual:

If more than one person prepared this document, attach additional sheets
conforming to the appropriate official form for each person.
A bankruptcy petition preparer’s failure to comply with the provisions of title 11
and the Federal Rules of Bankruptcy Procedure may result in fines or
imprisonment or both 11 U.S.C. §110; 18 U.S.C. §156.

0

.

3

e
g
n
a
h
C
X
-
F
D
P

-


0
1
1
1
0
-
X
1
0
3
-
1
3
1
2
3

-


4
7
7
-
7

.

6

.

4


.
r
e
v


,
.
c
n
I

,
e
r
a
w

t
f
o
S

e
p
o
H
w
e
N




,



2
1
0
2
-
1
9
9
1
©
2
1
0
2
y
c
t
p
u
r
k
n
a
B

Case 12-61259-mgd Doc 1 Filed 04/30/12 Entered 04/30/12 19:11:58 Desc Main

UNITED STATES BANKRUPTCY COURT

Document Page 4 of 47

Northern District of Georgia

In re

Tom Thomas

,

Debtor

Case No.

Chapter

13

Voluntary Petition Continuation Sheet

Location
Where Filed:

Northern District of Georgia

Additional Prior Bankruptcy Case(s) Filed Within Last 8 Years

Case Number:
10-96745

Date Filed:

2010

Case 12-61259-mgd Doc 1 Filed 04/30/12 Entered 04/30/12 19:11:58 Desc Main

Document Page 5 of 47

B1 D (Official Form 1, Exhibit D ) (12/09)

UNITED STATES BANKRUPTCY COURT

Northern District of Georgia

In re______________________________________

Tom Thomas

Debtor(s)

Case No._____________

(if known)

EXHIBIT D - INDIVIDUAL DEBTOR'S STATEMENT OF COMPLIANCE WITH

CREDIT COUNSELING REQUIREMENT

Warning: You must be able to check truthfully one of the five statements regarding
credit counseling listed below. If you cannot do so, you are not eligible to file a bankruptcy
case, and the court can dismiss any case you do file. If that happens, you will lose whatever
filing fee you paid, and your creditors will be able to resume collection activities against
you. If your case is dismissed and you file another bankruptcy case later, you may be
required to pay a second filing fee and you may have to take extra steps to stop creditors'
collection activities.

Every individual debtor must file this Exhibit D. If a joint petition is filed, each spouse
must complete and file a separate Exhibit D. Check one of the five statements below and attach
any documents as directed.

1. Within the 180 days before the filing of my bankruptcy case, I received a briefing

from a credit counseling agency approved by the United States trustee or bankruptcy
administrator that outlined the opportunities for available credit counseling and assisted me in
performing a related budget analysis, and I have a certificate from the agency describing the
services provided to me. Attach a copy of the certificate and a copy of any debt repayment plan
developed through the agency.

2. Within the 180 days before the filing of my bankruptcy case, I received a briefing

from a credit counseling agency approved by the United States trustee or bankruptcy
administrator that outlined the opportunities for available credit counseling and assisted me in
performing a related budget analysis, but I do not have a certificate from the agency describing
the services provided to me. You must file a copy of a certificate from the agency describing the
services provided to you and a copy of any debt repayment plan developed through the agency
no later than 14 days after your bankruptcy case is filed.

0
0

.
.

3
3


e
e
g
g
n
n
a
a
h
h
C
C
X
X
-
-
F
F
D
D
P
P


-
-



0
0
1
1
1
1
1
1
0
0
-
-
X
X
1
1
0
0
3
3
-
-
1
1
3
3
1
1
2
2
3
3


-
-



4
4
7
7
7
7
-
-
7
7

.
.

6
6

.
.

4
4



.
.
r
r
e
e
v
v



,
,
.
.
c
c
n
n
I
I


,
,
e
e
r
r
a
a
w
w

t
t
f
f
o
o
S
S


e
e
p
p
o
o
H
H
w
w
e
e
N
N






,
,




2
2
1
1
0
0
2
2
-
-
1
1
9
9
9
9
1
1
©
©
2
2
1
1
0
0
2
2
y
y
c
c
t
t
p
p
u
u
r
r
k
k
n
n
a
a
B
B

Case 12-61259-mgd Doc 1 Filed 04/30/12 Entered 04/30/12 19:11:58 Desc Main

B1 D (Official Form 1, Exh. D) (12/09) – Cont. Page 2

Document Page 6 of 47

3. I certify that I requested credit counseling services from an approved agency but

was unable to obtain the services during the seven days from the time I made my request, and the
following exigent circumstances merit a temporary waiver of the credit counseling requirement
so I can file my bankruptcy case now. [Summarize exigent circumstances here.]

If your certification is satisfactory to the court, you must still obtain the credit
counseling briefing within the first 30 days after you file your bankruptcy petition and
promptly file a certificate from the agency that provided the counseling, together with a
copy of any debt management plan developed through the agency. Failure to fulfill these
requirements may result in dismissal of your case. Any extension of the 30-day deadline
can be granted only for cause and is limited to a maximum of 15 days. Your case may also
be dismissed if the court is not satisfied with your reasons for filing your bankruptcy case
without first receiving a credit counseling briefing.

4. I am not required to receive a credit counseling briefing because of: [Check the
applicable statement.] [Must be accompanied by a motion for determination by the court.]

Incapacity. (Defined in 11 U.S.C. § 109(h)(4) as impaired by reason of mental

illness or mental deficiency so as to be incapable of realizing and making rational
decisions with respect to financial responsibilities.);

Disability. (Defined in 11 U.S.C. § 109(h)(4) as physically impaired to the
extent of being unable, after reasonable effort, to participate in a credit counseling
briefing in person, by telephone, or through the Internet.);

Active military duty in a military combat zone.

5. The United States trustee or bankruptcy administrator has determined that the credit

counseling requirement of 11 U.S.C. § 109(h) does not apply in this district.

I certify under penalty of perjury that the information provided above is true and

correct.

0
0

.
.

3
3


e
e
g
g
n
n
a
a
h
h
C
C
X
X
-
-
F
F
D
D
P
P


-
-



0
0
1
1
1
1
1
1
0
0
-
-
X
X
1
1
0
0
3
3
-
-
1
1
3
3
1
1
2
2
3
3


-
-



4
4
7
7
7
7
-
-
7
7

.
.

6
6

.
.

4
4



.
.
r
r
e
e
v
v



,
,
.
.
c
c
n
n
I
I


,
,
e
e
r
r
a
a
w
w

t
t
f
f
o
o
S
S


e
e
p
p
o
o
H
H
w
w
e
e
N
N






,
,




2
2
1
1
0
0
2
2
-
-
1
1
9
9
9
9
1
1
©
©
2
2
1
1
0
0
2
2
y
y
c
c
t
t
p
p
u
u
r
r
k
k
n
n
a
a
B
B

Signature of Debtor:

/s/ Tom Thomas
TOM THOMAS

Date: _________________

4-30-12

Case 12-61259-mgd Doc 1 Filed 04/30/12 Entered 04/30/12 19:11:58 Desc Main

Document Page 7 of 47

B6 Summary (Official Form 6 - Summary) (12/07)

Tom Thomas

In re

United States Bankruptcy Court

Northern District of Georgia

Case No.

Debtor

Chapter
SUMMARY OF SCHEDULES

13

Indicate as to each schedule whether that schedule is attached and state the number of pages in each. Report the totals from Schedules A, B, D, E, F,
I, and J in the boxes provided. Add the amounts from Schedules A and B to determine the total amount of the debtor’s assets. Add the amounts of all
claims from Schedules D, E, and F to determine the total amount of the debtor’s liabilities. Individual debtors must also complete the “Statistical
Summary of Certain Liabilities and Related Data” if they file a case under chapter 7, 11, or 13.

NAME OF SCHEDULE

A – Real Property

B – Personal Property

C – Property Claimed
as exempt

D – Creditors Holding
Secured Claims

0

.

3

e
g
n
a
h
C
X
-
F
D
P

-


0
1
1
1
0
-
X
1
0
3
-
1
3
1
2
3

-


4
7
7
-
7

.

6

.

4


.
r
e
v


,
.
c
n
I

,
e
r
a
w

t
f
o
S

e
p
o
H
w
e
N




,



2
1
0
2
-
1
9
9
1
©
2
1
0
2
y
c
t
p
u
r
k
n
a
B

E - Creditors Holding Unsecured
Priority Claims
(Total of Claims on Schedule E)
F - Creditors Holding Unsecured
Nonpriority Claims

G - Executory Contracts and
Unexpired Leases

H - Codebtors

I - Current Income of
Individual Debtor(s)

J - Current Expenditures of Individual
Debtors(s)

AMOUNTS SCHEDULED

ATTACHED
(YES/NO)

NO. OF SHEETS

ASSETS

LIABILITIES

OTHER

$

$

49,000.00

11,200.00

$

$

$

185,058.00

0.00

8,833.00

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

1

3

1

2

3

1

1

1

1

1

$

$

3,649.00

3,269.00

TOTAL

15

$

60,200.00

$

193,891.00

Official Form 6 - Statistical Summary (12/07)

Case 12-61259-mgd Doc 1 Filed 04/30/12 Entered 04/30/12 19:11:58 Desc Main

United States Bankruptcy Court

Document Page 8 of 47
Northern District of Georgia

In re

Tom Thomas

Debtor

Case No.

Chapter

13

STATISTICAL SUMMARY OF CERTAIN LIABILITIES AND RELATED DATA (28 U.S.C. § 159)

If you are an individual debtor whose debts are primarily consumer debts, as defined in § 101(8) of the Bankruptcy Code (11 U.S.C.
§101(8)), filing a case under chapter 7, 11 or 13, you must report all information requested below.

Check this box if you are an individual debtor whose debts are NOT primarily consumer debts. You are not required to report any
information here.

This information is for statistical purposes only under 28 U.S.C. § 159.

Summarize the following types of liabilities, as reported in the Schedules, and total them.

Type of Liability

Amount

Domestic Support Obligations (from Schedule E)

Taxes and Certain Other Debts Owed to Governmental Units (from
Schedule E)

Claims for Death or Personal Injury While Debtor Was Intoxicated (from
Schedule E) (whether disputed or undisputed)

Student Loan Obligations (from Schedule F)

Domestic Support, Separation Agreement, and Divorce Decree
Obligations Not Reported on Schedule E

Obligations to Pension or Profit-Sharing, and Other Similar Obligations
(from Schedule F)

TOTAL

State the Following:
Average Income (from Schedule I, Line 16)

Average Expenses (from Schedule J, Line 18)

Current Monthly Income (from Form 22A Line 12; OR, Form
22B Line 11; OR, Form 22C Line 20 )

State the Following:
1. Total from Schedule D, “UNSECURED PORTION, IF
ANY” column

2. Total from Schedule E, “AMOUNT ENTITLED TO
PRIORITY” column.

3. Total from Schedule E, “AMOUNT NOT ENTITLED TO
PRIORITY, IF ANY” column

4. Total from Schedule F

5. Total of non-priority unsecured debt (sum of 1, 3, and 4)

$

$

$

$

$

$

$

$

$

$

$

0.00

0.00

0.00
0.00

0.00

0.00

0.00

3,649.00

3,269.00

4,770.00

0.00

$

$

$

$

128,357.00

0.00

8,833.00

137,190.00

0

.

3

e
g
n
a
h
C
X
-
F
D
P

-


0
1
1
1
0
-
X
1
0
3
-
1
3
1
2
3

-


4
7
7
-
7

.

6

.

4


.
r
e
v


,
.
c
n
I

,
e
r
a
w

t
f
o
S

e
p
o
H
w
e
N




,



2
1
0
2
-
1
9
9
1
©
2
1
0
2
y
c
t
p
u
r
k
n
a
B

B6 (Official Form 6 - Declaration) (12/07)

Case 12-61259-mgd Doc 1 Filed 04/30/12 Entered 04/30/12 19:11:58 Desc Main

Document Page 9 of 47

Tom Thomas

In re

Debtor

Case No.

(If known)

DECLARATION CONCERNING DEBTOR'S SCHEDULES

DECLARATION UNDER PENALTY OF PERJURY BY INDIVIDUAL DEBTOR

I declare under penalty of perjury that I have read the foregoing summary and schedules, consisting of _______ sheets, and that they

17

are true and correct to the best of my knowledge, information, and belief.

Date

4-30-12

Date

Signature:

/s/ Tom Thomas

Debtor

Signature:

Not Applicable

(Joint Debtor, if any)

[If joint case, both spouses must sign.]

-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

DECLARATION AND SIGNATURE OF NON-ATTORNEY BANKRUPTCY PETITION PREPARER (See 11 U.S.C. § 110)

I declare under penalty of perjury that: (1) I am a bankruptcy petition preparer as defined in 11 U.S.C. § 110; (2) I prepared this document for
compensation and have provided the debtor with a copy of this document and the notices and information required under 11 U.S.C. §§ 110(b),
110(h) and 342(b); and, (3) if rules or guidelines have been promulgated pursuant to 11 U.S.C. § 110 setting a maximum fee for services chargeable
by bankruptcy petition preparers, I have given the debtor notice of the maximum amount before preparing any document for filing for a debtor or
accepting any fee from the debtor, as required by that section.

Printed or Typed Name and Title, if any,
of Bankruptcy Petition Preparer
If the bankruptcy petition preparer is not an individual, state the name, title (if any), address, and social security number of the officer, principal, responsible person, or partner
who signs this document.

(Required by 11 U.S.C. § 110.)

Social Security No.

Address

X

Signature of Bankruptcy Petition Preparer

Date

Names and Social Security numbers of all other individuals who prepared or assisted in preparing this document, unless the bankruptcy petition preparer is not an individual:

If more than one person prepared this document, attach additional signed sheets conforming to the appropriate Official Form for each person.

A bankruptcy petition preparer's failure to comply with the provisions of title 11 and the Federal Rules of Bankruptcy Procedure may result in fines or imprisonment or both. 11 U.S.C. § 110;
18 U.S.C. § 156.
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

DECLARATION UNDER PENALTY OF PERJURY ON BEHALF OF A CORPORATION OR PARTNERSHIP

I, the __________________________________ [the president or other officer or an authorized agent of the corporation or a member
or an authorized agent of the partnership ] of the ___________________________________ [corporation or partnership] named as debtor
in this case, declare under penalty of perjury that I have read the foregoing summary and schedules, consisting of _______sheets (total
shown on summary page plus 1),and that they are true and correct to the best of my knowledge, information, and belief.

Date

Signature:

-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

[An individual signing on behalf of a partnership or corporation must indicate position or relationship to debtor.]

Penalty for making a false statement or concealing property: Fine of up to $500,000 or imprisonment for up to 5 years or both. 18 U.S.C. §§ 152 and 3571.

[Print or type name of individual signing on behalf of debtor.]

0

.

3

e
g
n
a
h
C
X
-
F
D
P

-


0
1
1
1
0
-
X
1
0
3
-
1
3
1
2
3

-


4
7
7
-
7

.

6

.

4


.
r
e
v


,
.
c
n
I

,
e
r
a
w

t
f
o
S

e
p
o
H
w
e
N




,



2
1
0
2
-
1
9
9
1
©
2
1
0
2
y
c
t
p
u
r
k
n
a
B

Case 12-61259-mgd Doc 1 Filed 04/30/12 Entered 04/30/12 19:11:58 Desc Main

Document Page 10 of 47

B6 Cover (Form 6 Cover) (12/07)

FORM 6. SCHEDULES

Summary of Schedules
Statistical Summary of Certain Liabilities and Related Data (28 U.S.C. § 159)
Schedule A - Real Property
Schedule B - Personal Property
Schedule C - Property Claimed as Exempt
Schedule D - Creditors Holding Secured Claims
Schedule E - Creditors Holding Unsecured Priority Claims
Schedule F - Creditors Holding Unsecured Nonpriority Claims
Schedule G - Executory Contracts and Unexpired Leases
Schedule H - Codebtors
Schedule I - Current Income of Individual Debtor(s)
Schedule J - Current Expenditures of Individual Debtor(s)

Unsworn Declaration under Penalty of Perjury

GENERAL INSTRUCTIONS: The first page of the debtor’s schedules and the first page of any
amendments thereto must contain a caption as in Form 16B. Subsequent pages should be
identified with the debtor’s name and case number. If the schedules are filed with the petition,
the case number should be left blank

Schedules D, E, and F have been designed for the listing of each claim only once. Even when a
claim is secured only in part or entitled to priority only in part, it still should be listed only once.
A claim which is secured in whole or it part should be listed on Schedule D only, and a claim
which is entitled to priority in whole or in part should be listed on Schedule E only. Do not list
the same claim twice. If a creditor has more than one claim, such as claims arising from separate
transactions, each claim should be scheduled separately.

Review the specific instructions for each schedule before completing the schedule.

0

.

3

e
g
n
a
h
C
X
-
F
D
P

-


0
1
1
1
0
-
X
1
0
3
-
1
3
1
2
3

-


4
7
7
-
7

.

6

.

4


.
r
e
v


,
.
c
n
I

,
e
r
a
w

t
f
o
S

e
p
o
H
w
e
N




,



2
1
0
2
-
1
9
9
1
©
2
1
0
2
y
c
t
p
u
r
k
n
a
B

B6A (Official Form 6A) (12/07)

Case 12-61259-mgd Doc 1 Filed 04/30/12 Entered 04/30/12 19:11:58 Desc Main

Document Page 11 of 47

In re

Tom Thomas

Debtor

SCHEDULE A - REAL PROPERTY

Case No.

(If known)

Except as directed below, list all real property in which the debtor has any legal, equitable, or future interest, including all property owned as a co-
tenant, community property, or in which the debtor has a life estate. Include any property in which the debtor holds rights and powers exercisable for
the debtor’s own benefit. If the debtor is married, state whether husband, wife, both, or the marital community own the property by placing an “H,”
“W,” “J,” or “C” in the column labeled “Husband, Wife, Joint, or Community.” If the debtor holds no interest in real property, write “None” under
“Description and Location of Property.”

Do not include interests in executory contracts and unexpired leases on this schedule. List them in Schedule G - Executory Contracts and
Unexpired Leases.

If an entity claims to have a lien or hold a secured interest in any property, state the amount of the secured claim. See Schedule D. If no entity
claims to hold a secured interest in the property, write “None” in the column labeled “Amount of Secured Claim.”

If the debtor is an individual or if a joint petition is filed, state the amount of any exemption claimed in the property only in Schedule C –
Property Claimed as Exempt.

I

T
N
O
J

,

E
F
I
W


,

D
N
A
B
S
U
H

OF DEBTOR’S
INTEREST IN

Y CURRENT VALUE
T
I
N
U
M
M
O
C
R
O

DEDUCTING ANY
SECURED CLAIM
OR EXEMPTION

PROPERTY, WITHOUT



AMOUNT OF
SECURED
CLAIM

DESCRIPTION AND LOCATION

OF PROPERTY

NATURE OF DEBTOR’S
INTEREST IN PROPERTY

Tenancy in Common

49,000.00

167,000.00

0

.

3

e
g
n
a
h
C
X
-
F
D
P

-


0
1
1
1
0
-
X
1
0
3
-
1
3
1
2
3

-


4
7
7
-
7

.

6

.

Former Residence
5603 Old Orchard Court
Rex, GA 30273

5603 Old Orchard Court
Rex, GA 30273

4


.
r
e
v


,
.
c
n
I

,
e
r
a
w

t
f
o
S

e
p
o
H
w
e
N




,



2
1
0
2
-
1
9
9
1
©
2
1
0
2
y
c
t
p
u
r
k
n
a
B

Total

49,000.00

(Report also on Summary of Schedules.)

B6B (Official Form 6B) (12/07)

Case 12-61259-mgd Doc 1 Filed 04/30/12 Entered 04/30/12 19:11:58 Desc Main

Document Page 12 of 47

In re

Tom Thomas

Debtor

Case No.

(If known)

SCHEDULE B - PERSONAL PROPERTY

Except as directed below, list all personal property of the debtor of whatever kind. If the debtor has no property in one or more of the categories,
place an “x” in the appropriate position in the column labeled “None.” If additional space is needed in any category, attach a separate sheet properly
identified with the case name, case number, and the number of the category. If the debtor is married, state whether husband, wife, both, or the marital
community own the property by placing an “H,” “W,” “J,” or “C” in the column labeled “Husband, Wife, Joint, or Community.” If the debtor is an
individual or a joint petition is filed, state the amount of any exemptions claimed only in Schedule C - Property Claimed as Exempt.

Do not list interests in executory contracts and unexpired leases on this schedule. List them in Schedule G - Executory Contracts and
Unexpired Leases.

If the property is being held for the debtor by someone else, state that person’s name and address under “Description and Location of Property.”
If the property is being held for a minor child, simply state the child's initials and the name and address of the child's parent or guardian, such as
"A.B., a minor child, by John Doe, guardian." Do not disclose the child's name. See. 11 U.S.C. § 112 and Fed. R. Bankr. P. 1007(m).

0

.

3

e
g
n
a
h
C
X
-
F
D
P

-


0
1
1
1
0
-
X
1
0
3
-
1
3
1
2
3

-


4
7
7
-
7

.

6

.

4


.
r
e
v


,
.
c
n
I

,
e
r
a
w

t
f
o
S

e
p
o
H
w
e
N




,



2
1
0
2
-
1
9
9
1
©
2
1
0
2
y
c
t
p
u
r
k
n
a
B

TYPE OF PROPERTY

1. Cash on hand.

2. Checking, savings or other financial accounts,
certificates of deposit, or shares in banks, savings
and loan, thrift, building and loan, and homestead
associations, or credit unions, brokerage houses,
or cooperatives.

3. Security deposits with public utilities,
telephone companies, landlords, and others.

4. Household goods and furnishings, including
audio, video, and computer equipment.

5. Books. Pictures and other art objects,
antiques, stamp, coin, record, tape, compact disc,
and other collections or collectibles.

6. Wearing apparel.

7. Furs and jewelry.

8. Firearms and sports, photographic, and other
hobby equipment.

9. Interests in insurance policies. Name
insurance company of each policy and itemize
surrender or refund value of each.

10. Annuities. Itemize and name each issuer.

11. Interests in an education IRA as defined in 26
U.S.C. § 530(b)(1) or under a qualified State
tuition plan as defined in 26 U.S.C. § 529(b)(1).
Give particulars. (File separately the record(s) of
any such interest(s). 11 U.S.C. § 521(c).)

12. Interests in IRA, ERISA, Keogh, or other
pension or profit sharing plans. Give particulars.

13. Stock and interests in incorporated and
unincorporated businesses. Itemize.

N
O
N
E

X

X

X

X
X

X

X
X

X

DESCRIPTION AND LOCATION

OF PROPERTY

I

T
N
O
J

,

E
F
I
W


,

D
N
A
B
S
U
H

Y
T
I
N
U
M
M
O
C
R
O



CURRENT VALUE OF
DEBTOR’S INTEREST

IN PROPERTY,

WITHOUT

DEDUCTING ANY
SECURED CLAIM
OR EXEMPTION

Savings

Household Goods

Clothing

H

J

H

100.00

3,000.00

500.00

The debtor has a retirement with the US Military.

H

100.00

B6B (Official Form 6B) (12/07) -- Cont.

Case 12-61259-mgd Doc 1 Filed 04/30/12 Entered 04/30/12 19:11:58 Desc Main

Document Page 13 of 47

In re

Tom Thomas

Debtor

Case No.

(If known)

SCHEDULE B - PERSONAL PROPERTY

(Continuation Sheet)

DESCRIPTION AND LOCATION

OF PROPERTY

I

T
N
O
J

,

E
F
I
W


,

D
N
A
B
S
U
H

Y
T
I
N
U
M
M
O
C
R
O



CURRENT VALUE OF
DEBTOR’S INTEREST

IN PROPERTY,

WITHOUT

DEDUCTING ANY
SECURED CLAIM
OR EXEMPTION

2002 Lincoln Towncar
2000 Cadillac DeVille
Vehicle has been repossed by lender

H
H

4,000.00
3,500.00

TYPE OF PROPERTY

14. Interests in partnerships or joint ventures.
Itemize.

15. Government and corporate bonds and other
negotiable and non-negotiable instruments.

16. Accounts receivable.

17. Alimony, maintenance, support, and property
settlement to which the debtor is or may be
entitled. Give particulars.

18. Other liquidated debts owing debtor including
tax refunds. Give particulars.

19. Equitable or future interests, life estates, and
rights or powers exercisable for the benefit of the
debtor other than those listed in Schedule A -
Real Property.

20. Contingent and noncontingent interests in
estate or a decedent, death benefit plan, life
insurance policy, or trust.

21. Other contingent and unliquidated claims of
every nature, including tax refunds, counterclaims
of the debtor, and rights of setoff claims. Give
estimated value of each.

22. Patents, copyrights, and other intellectual
property. Give particulars.

23. Licenses, franchises, and other general
intangibles. Give particulars.

24. Customer lists or other compilations
containing personally identifiable information (as
defined in 11 U.S.C. §101(41A)) provided to the
debtor by individuals in connection with obtaining
a product or service from the debtor primarily for
personal, family, or household purposes.

25. Automobiles, trucks, trailers, and other
vehicles and accessories.

26. Boats, motors, and accessories.

27. Aircraft and accessories.

28. Office equipment, furnishings, and supplies.

29. Machinery, fixtures, equipment, and supplies
used in business.

N
O
N
E

X

X

X
X

X

X

X

X

X

X

X

X
X
X
X

0

.

3

e
g
n
a
h
C
X
-
F
D
P

-


0
1
1
1
0
-
X
1
0
3
-
1
3
1
2
3

-


4
7
7
-
7

.

6

.

4


.
r
e
v


,
.
c
n
I

,
e
r
a
w

t
f
o
S

e
p
o
H
w
e
N




,



2
1
0
2
-
1
9
9
1
©
2
1
0
2
y
c
t
p
u
r
k
n
a
B

B6B (Official Form 6B) (12/07) -- Cont.

Case 12-61259-mgd Doc 1 Filed 04/30/12 Entered 04/30/12 19:11:58 Desc Main

Document Page 14 of 47

In re

Tom Thomas

Debtor

Case No.

(If known)

SCHEDULE B - PERSONAL PROPERTY

(Continuation Sheet)

IN PROPERTY,

WITHOUT

CURRENT VALUE OF
DEBTOR’S INTEREST

DEDUCTING ANY
SECURED CLAIM
OR EXEMPTION

I

T
N
O
J

,

E
F
I
W


,

D
N
A
B
S
U
H

Y
T
I
N
U
M
M
O
C
R
O



DESCRIPTION AND LOCATION

OF PROPERTY

TYPE OF PROPERTY

30. Inventory.

31. Animals.

32. Crops - growing or harvested. Give
particulars.

33. Farming equipment and implements.

34. Farm supplies, chemicals, and feed.

35. Other personal property of any kind not
already listed. Itemize.

N
O
N
E

X
X
X

X
X
X

0

.

3

e
g
n
a
h
C
X
-
F
D
P

-


0
1
1
1
0
-
X
1
0
3
-
1
3
1
2
3

-


4
7
7
-
7

.

6

.

4


.
r
e
v


,
.
c
n
I

,
e
r
a
w

t
f
o
S

e
p
o
H
w
e
N




,



2
1
0
2
-
1
9
9
1
©
2
1
0
2
y
c
t
p
u
r
k
n
a
B

0

continuation sheets attached Total
(Include amounts from any continuation

sheets attached. Report total also on

Summary of Schedules.)

$

11,200.00

Case 12-61259-mgd Doc 1 Filed 04/30/12 Entered 04/30/12 19:11:58 Desc Main

B6C (Official Form 6C) (04/10)

Document Page 15 of 47

In re

Tom Thomas

Debtor
SCHEDULE C - PROPERTY CLAIMED AS EXEMPT

(If known)

Case No.

Debtor claims the exemptions to which debtor is entitled under:
(Check one box)

11 U.S.C. § 522(b)(2)
11 U.S.C. § 522(b)(3)

Check if debtor claims a homestead exemption that exceeds
$146,450*.

DESCRIPTION OF PROPERTY

SPECIFY LAW

PROVIDING EACH

EXEMPTION

Savings

Household Goods

Clothing

OCGA §44-13-100(6)

OCGA §44-13-100(4)

OCGA §44-13-100(4)

The debtor has a retirement with the US
Military.

OCGA §44-13-100(2)(E)

2002 Lincoln Towncar

2000 Cadillac DeVille

OCGA §44-13-100(3)

OCGA §44-13-100(3)

0

.

3

e
g
n
a
h
C
X
-
F
D
P

-


0
1
1
1
0
-
X
1
0
3
-
1
3
1
2
3

-


4
7
7
-
7

.

6

.

4


.
r
e
v


,
.
c
n
I

,
e
r
a
w

VALUE OF
CLAIMED

EXEMPTION

100.00

3,000.00

500.00

100.00

100.00

100.00

CURRENT

VALUE OF PROPERTY
WITHOUT DEDUCTING

EXEMPTION

100.00

3,000.00

500.00

100.00

4,000.00

3,500.00

t
f
o
S

e
p
o
H
w
e
N




,



2
1
0
2
-
1
9
9
1
©
2
1
0
2
y
c
t
p
u
r
k
n
a
B

*Amount subject to adjustment on 4/1/13 and every three years thereafter with respect to cases commenced on or after the date of adjustment.

Case 12-61259-mgd Doc 1 Filed 04/30/12 Entered 04/30/12 19:11:58 Desc Main

Document Page 16 of 47

B6D (Official Form 6D) (12/07)

In re _______________________________________________,

Tom Thomas

Debtor

Case No. _________________________________

(If known)

SCHEDULE D - CREDITORS HOLDING SECURED CLAIMS

State the name, mailing address, including zip code and last four digits of any account number of all entities holding claims secured
by property of the debtor as of the date of filing of the petition. The complete account number of any account the debtor has with the creditor is
useful to the trustee and the creditor and may be provided if the debtor chooses to do so. List creditors holding all types of secured interests
such as judgment liens, garnishments, statutory liens, mortgages, deeds of trust, and other security interests.

List creditors in alphabetical order to the extent practicable. If a minor child is a creditor, state the child's initials and the name and
address of the child's parent or guardian, such as "A.B., a minor child, by John Doe, guardian." Do not disclose the child's name. See 11 U.S.C
§112 and Fed. R. Bankr. P. 1007(m). If all secured creditors will not fit on this page, use the continuation sheet provided.

If any entity other than a spouse in a joint case may be jointly liable on a claim, place an "X" in the column labeled "Codebtor,"
include the entity on the appropriate schedule of creditors, and complete Schedule H - Codebtors. If a joint petition is filed, state whether
husband, wife, both of them, or the marital community may be liable on each claim by placing an "H," "W," "J," or "C" in the column labeled
"Husband, Wife, Joint, or Community."

If the claim is contingent, place an "X" in the column labeled "Contingent." If the claim is unliquidated, place an "X" in the column
labeled "Unliquidated." If the claim is disputed, place an "X" in the column labeled "Disputed." (You may need to place an "X" in more than
one of these three columns.)

Total the columns labeled “Amount of Claim Without Deducting Value of Collateral” and “Unsecured Portion, if Any” in the boxes
labeled “Total(s)” on the last sheet of the completed schedule. Report the total from the column labeled “Amount of Claim Without Deducting
Value of Collateral” also on the Summary of Schedules and, if the debtor is an individual with primarily consumer debts, report the total from
the column labeled “Unsecured Portion, if Any” on the Statistical Summary of Certain Liabilities and Related Data.

Check this box if debtor has no creditors holding secured claims to report on this Schedule D.

T
N
I
O
J


,

E
F
I
W


,

D
N
A
B
S
U
H

Y
T
I
N
U
M
M
O
C
R
O

CREDITOR’S NAME,
MAILING ADDRESS

INCLUDING ZIP CODE,
AND ACCOUNT NUMBER

(See Instructions Above.)

R
O
T
B
E
D
O
C

ACCOUNT NO.

American Financial Services
PO Box 307
Forest Park, GA 30298

ACCOUNT NO.
Covington Credit-Ga12
3859 Hwy 138 SE
Stockbridge, GA 30281

ACCOUNT NO.
Fort McPherson Credit Union
c/o Charles Gisler, Esq.
165 North Main Street
Jonesboro, GA 30236-3568

1

_______continuation sheets attached

DATE CLAIM WAS INCURRED,

NATURE OF LIEN, AND

DESCRIPTION AND

VALUE OF PROPERTY

SUBJECT TO LIEN

T
N
E
G
N
I
T
N
O
C

D
E
T
A
D
I
U
Q

I
L
N
U

D
E
T
U
P
S
I
D

AMOUNT

OF

CLAIM

WITHOUT
DEDUCTING
VALUE OF

COLLATERAL

Lien: Title Lien
Security: 2000 Cadillac DeVille
and 2002 Lincoln Towncar

VALUE $
Lien: NonPMSI in HHG
Security: Household Goods

7,500.00

VALUE $
Lien: fifa
Security: Judgment

200.00

VALUE $

1.00

8,327.00

1,089.00

8,642.00

UNSECURED
PORTION,

IF ANY

827.00

889.00

8,641.00

Subtotal $

18,058.00

$

10,357.00

(Total of this page)
(Use only on last page)

Total

$

(Report also on
Summary of Schedules)

$
(If applicable, report
also on Statistical
Summary of Certain
Liabilities and Related
Data.)

0

.

3

e
g
n
a
h
C
X
-
F
D
P

-


0
1
1
1
0
-
X
1
0
3
-
1
3
1
2
3

-


4
7
7
-
7

.

6

.

4


.
r
e
v


,
.
c
n
I

,
e
r
a
w

t
f
o
S

e
p
o
H
w
e
N




,



2
1
0
2
-
1
9
9
1
©
2
1
0
2
y
c
t
p
u
r
k
n
a
B

Case 12-61259-mgd Doc 1 Filed 04/30/12 Entered 04/30/12 19:11:58 Desc Main

Document Page 17 of 47

B6D (Official Form 6D) (12/07) – Cont.

In re __________________________________________________,

Tom Thomas

Case No. _________________________________

Debtor

(If known)

SCHEDULE D - CREDITORS HOLDING SECURED CLAIMS

(Continuation Sheet)

CREDITOR’S NAME,
MAILING ADDRESS

INCLUDING ZIP CODE,
AND ACCOUNT NUMBER

(See Instructions Above.)

R
O
T
B
E
D
O
C

T
N
I
O
J

,

E
F
I
W


,

D
N
A
B
S
U
H

Y
T
I
N
U
M
M
O
C
R
O

DATE CLAIM WAS INCURRED,

NATURE OF LIEN, AND

DESCRIPTION AND

VALUE OF PROPERTY

SUBJECT TO LIEN

T
N
E
G
N
I
T
N
O
C

D
E
T
A
D
I
U
Q

I
L
N
U

D
E
T
U
P
S
I
D

AMOUNT

OF

CLAIM

WITHOUT
DEDUCTING
VALUE OF

COLLATERAL

ACCOUNT NO.

GMAC Mortgage, LLC
c/o McCurdy & Candler, LLC
Sidney Gelernter
3525 Piedmont Road NE, Bldg. 6, Ste.
700
Atlanta, GA 30305
ACCOUNT NO.

Lien: First Mortgage
Security: 5306 Old Orchard Ct

VALUE $

49,000.00

167,000.00

UNSECURED
PORTION,

IF ANY

118,000.00

0

.

3

e
g
n
a
h
C
X
-
F
D
P

-


0
1
1
1
0
-
X
1
0
3
-
1
3
1
2
3

-


4
7
7
-
7

.

6

.

4


.
r
e
v


,
.
c
n
I

,
e
r
a
w

ACCOUNT NO.

t
f
o
S

e
p
o
H
w
e
N




,



2
1
0
2
-
1
9
9
1
©
2
1
0
2
y
c
t
p
u
r
k
n
a
B

ACCOUNT NO.

ACCOUNT NO.

1

1

Sheet no. ___ of ___continuation sheets attached to
Schedule of Creditors Holding Secured Claims

VALUE $

VALUE $

VALUE $

VALUE $

Subtotal (s) $

167,000.00

$

118,000.00

(Total(s) of this page)
Total(s)
(Use only on last page)

185,058.00

$
(Report also on
Summary of Schedules)

128,357.00

$
(If applicable, report
also on Statistical
Summary of Certain
Liabilities and Related
Data.)

Case 12-61259-mgd Doc 1 Filed 04/30/12 Entered 04/30/12 19:11:58 Desc Main

Document Page 18 of 47

B6E (Official Form 6E) (04/10)

In re________________________________________________________________,

Tom Thomas

Debtor

Case No.______________________________

(if known)

SCHEDULE E - CREDITORS HOLDING UNSECURED PRIORITY CLAIMS
A complete list of claims entitled to priority, listed separately by type of priority, is to be set forth on the sheets provided. Only holders of

unsecured claims entitled to priority should be listed in this schedule. In the boxes provided on the attached sheets, state the name, mailing
address, including zip code, and last four digits of the account number, if any, of all entities holding priority claims against the debtor or the
property of the debtor, as of the date of the filing of the petition. Use a separate continuation sheet for each type of priority and label each with
the type of priority.

The complete account number of any account the debtor has with the creditor is useful to the trustee and the creditor and may be provided if
the debtor chooses to do so. If a minor child is a creditor, state the child's initials and the name and address of the child's parent or guardian, such as
"A.B., a minor child, by John Doe, guardian." Do not disclose the child's name. See 11 U.S.C. § 112 and Fed.R.Bankr.P. 1007(m).

If any entity other than a spouse in a joint case may be jointly liable on a claim, place an "X" in the column labeled "Codebtor," include the

entity on the appropriate schedule of creditors, and complete Schedule H-Codebtors. If a joint petition is filed, state whether husband, wife,
both of them or the marital community may be liable on each claim by placing an "H,""W,""J," or "C" in the column labeled "Husband, Wife,
Joint, or Community." If the claim is contingent, place an "X" in the column labeled "Contingent." If the claim is unliquidated, place an "X"
in the column labeled "Unliquidated." If the claim is disputed, place an "X" in the column labeled "Disputed." (You may need to place an "X" in
more than one of these three columns.)

Report the total of claims listed on each sheet in the box labeled "Subtotals" on each sheet. Report the total of all claims listed on this

Schedule E in the box labeled "Total" on the last sheet of the completed schedule. Report this total also on the Summary of Schedules.

Report the total of amounts entitled to priority listed on each sheet in the box labeled "Subtotals" on each sheet. Report the total of all

amounts entitled to priority listed on this Schedule E in the box labeled "Totals" on the last sheet of the completed schedule. Individual debtors with
primarily consumer debts report this total also on the Statistical Summary of Certain Liabilities and Related Data.

Report the total of amounts not entitled to priority listed on each sheet in the box labeled “Subtotals” on each sheet. Report the total of all
amounts not entitled to priority listed on this Schedule E in the box labeled “Totals” on the last sheet of the completed schedule. Individual debtors
with primarily consumer debts report this total also on the Statistical Summary of Certain Liabilities and Related
Data.

Check this box if debtor has no creditors holding unsecured priority claims to report on this Schedule E.

TYPES OF PRIORITY CLAIMS (Check the appropriate box(es) below if claims in that category are listed on the attached sheets)

Domestic Support Obligations

Claims for domestic support that are owed to or recoverable by a spouse, former spouse, or child of the debtor, or the parent, legal guardian,
or responsible relative of such a child, or a governmental unit to whom such a domestic support claim has been assigned to the extent provided in
11 U.S.C. § 507(a)(1).

Extensions of credit in an involuntary case

Claims arising in the ordinary course of the debtor's business or financial affairs after the commencement of the case but before the earlier of the

appointment of a trustee or the order for relief. 11 U.S.C. § 507(a)(3).

Wages, salaries, and commissions

Wages, salaries, and commissions, including vacation, severance, and sick leave pay owing to employees and commissions owing to qualifying

independent sales representatives up to $11,725* per person earned within 180 days immediately preceding the filing of the original petition, or the
cessation of business, whichever occurred first, to the extent provided in 11 U.S.C. § 507(a)(4).

Contributions to employee benefit plans

Money owed to employee benefit plans for services rendered within 180 days immediately preceding the filing of the original petition, or the

cessation of business, whichever occurred first, to the extent provided in 11 U.S.C. § 507(a)(5).

*Amount subject to adjustment on 4/1/13 and every three years thereafter with respect to cases commenced on or after the date of adjustment.

0

.

3

e
g
n
a
h
C
X
-
F
D
P

-


0
1
1
1
0
-
X
1
0
3
-
1
3
1
2
3

-


4
7
7
-
7

.

6

.

4


.
r
e
v


,
.
c
n
I

,
e
r
a
w

t
f
o
S

e
p
o
H
w
e
N




,



2
1
0
2
-
1
9
9
1
©
2
1
0
2
y
c
t
p
u
r
k
n
a
B

Case 12-61259-mgd Doc 1 Filed 04/30/12 Entered 04/30/12 19:11:58 Desc Main

Document Page 19 of 47

B6E (Official Form 6E) (04/10) - Cont.

In re________________________________________________________________,

Tom Thomas

Debtor

Case No.______________________________

(if known)

Certain farmers and fishermen

Claims of certain farmers and fishermen, up to $5,775* per farmer or fisherman, against the debtor, as provided in 11 U.S.C. § 507(a)(6).

Deposits by individuals

Claims of individuals up to $2,600* for deposits for the purchase, lease, or rental of property or services for personal, family, or household use,
that were not delivered or provided. 11 U.S.C. § 507(a)(7).

Taxes and Certain Other Debts Owed to Governmental Units

Taxes, customs duties, and penalties owing to federal, state, and local governmental units as set forth in 11 U.S.C. § 507(a)(8).

Commitments to Maintain the Capital of an Insured Depository Institution

Claims based on commitments to the FDIC, RTC, Director of the Office of Thrift Supervision, Comptroller of the Currency, or Board of
Governors of the Federal Reserve System, or their predecessors or successors, to maintain the capital of an insured depository institution. 11
U.S.C. § 507 (a)(9).

Claims for Death or Personal Injury While Debtor Was Intoxicated

Claims for death or personal injury resulting from the operation of a motor vehicle or vessel while the debtor was intoxicated from using

alcohol, a drug, or another substance. 11 U.S.C. § 507(a)(10).
alcohol, a drug, or another substance. 11 U.S.C. § 507(a)(10).

* Amounts are subject to adjustment on 4/01/13, and every three years thereafter with respect to cases commenced on or after the date of
adjustment.

1

____ continuation sheets attached

0

.

3

e
g
n
a
h
C
X
-
F
D
P

-


0
1
1
1
0
-
X
1
0
3
-
1
3
1
2
3

-


4
7
7
-
7

.

6

.

4


.
r
e
v


,
.
c
n
I

,
e
r
a
w

t
f
o
S

e
p
o
H
w
e
N




,



2
1
0
2
-
1
9
9
1
©
2
1
0
2
y
c
t
p
u
r
k
n
a
B

Case 12-61259-mgd Doc 1 Filed 04/30/12 Entered 04/30/12 19:11:58 Desc Main

Document Page 20 of 47

B6E (Official Form 6E) (04/10) - Cont.

In re __________________________________________________,

Tom Thomas

Debtor

Case No. _________________________________

(If known)

SCHEDULE E - CREDITORS HOLDING UNSECURED PRIORITY CLAIMS

(Continuation Sheet)

Sec. 507(a)(8)
Sec. 507(a)(8)

Type of Priority for Claims Listed on This Sheet

CREDITOR’S NAME,
MAILING ADDRESS

INCLUDING ZIP CODE,
AND ACCOUNT NUMBER

(See instructions above..)

R
O
T
B
E
D
O
C

T
N
I
O
J


,


,

E
F
I
W
D
N
A
B
S
U
H

Y
T
I
N
U
M
M
O
C
R
O

DATE CLAIM WAS
INCURRED AND
CONSIDERATION

FOR CLAIM

T
N
E
G
N
I
T
N
O
C

D
E
T
A
D
I
U
Q
I
L
N
U

D
E
T
U
P
S
I
D

AMOUNT

OF

CLAIM

AMOUNT

ENTITLED TO

PRIORITY

AMOUNT

NOT

ENTITLED

PRIORITY, IF

TO

ANY

ACCOUNT NO.

Internal Revenue Service, Insolvency
Room 400 Stop 334-D
401 West Peachtree Street
Atlanta, GA 30308

0

.

3

e
g
n
a
h
C
X
-
F
D
P

-


0
1
1
1
0
-
X
1
0
3
-
1
3
1
2
3

-


4
7
7
-
7

.

6

.

ACCOUNT NO.

IRS, Insolvency Section
PO Box 21126
Philadelphia, PA 19114

ACCOUNT NO.

Notice Only Notice Only

Notice Only

Notice Only Notice Only

Notice Only

4


.
r
e
v


,
.
c
n
I

,
e
r
a
w

t
f
o
S

e
p
o
H
w
e
N




,



2
1
0
2
-
1
9
9
1
©
2
1
0
2
y
c
t
p
u
r
k
n
a
B

ACCOUNT NO.

1

1

Sheet no. ___ of ___continuation sheets attached to Schedule of
Creditors Holding Priority Claims

Subtotal $

(Totals of this page)

0.00

$

0.00

$

0.00

Total
(Use only on last page of the completed
Schedule E.) Report also on the Summary
of Schedules)

Totals
(Use only on last page of the completed
Schedule E. If applicable, report also on
the Statistical Summary of Certain
Liabilities and Related Data.)

0.00

$

$

$

0.00

$

0.00

Case 12-61259-mgd Doc 1 Filed 04/30/12 Entered 04/30/12 19:11:58 Desc Main

Document Page 21 of 47

B6F (Official Form 6F) (12/07)

In re __________________________________________,

Tom Thomas

Debtor

Case No. _________________________________

(If known)

SCHEDULE F- CREDITORS HOLDING UNSECURED NONPRIORITY CLAIMS
State the name, mailing address, including zip code, and last four digits of any account number, of all entities holding unsecured claims without priority

against the debtor or the property of the debtor, as of the date of filing of the petition. The complete account number of any account the debtor has with the creditor is
useful to the trustee and the creditor and may be provided if the debtor chooses to do so. If a minor child is a creditor, state the child's initials and the name and address
of the child's parent or guardian, such as "A.B., a minor child, by John Doe, guardian." Do not disclose the child's name. See 11 U.S.C. § 112 and Fed. R. Bankr. P.
1007(m). Do not include claims listed in Schedules D and E. If all creditors will not fit on this page, use the continuation sheet provided.

If any entity other than a spouse in a joint case may be jointly liable on a claim, place an "X" in the column labeled "Codebtor," include the entity on the

appropriate schedule of creditors, and complete Schedule H - Codebtors. If a joint petition is filed, state whether husband, wife, both of them, or the marital
community may be liable on each claim by placing an "H," "W," "J," or "C" in the column labeled "Husband, Wife, Joint, or Community."

If the claim is contingent, place an "X" in the column labeled "Contingent." If the claim is unliquidated, place an "X" in the column labeled

"Unliquidated." If the claim is disputed, place an "X" in the column labeled "Disputed." (You may need to place an "X" in more than one of these three columns.)

Report the total of all claims listed on this schedule in the box labeled "Total" on the last sheet of the completed schedule. Report this total also on the
Summary of Schedules and, if the debtor is an individual with primarily consumer debts, report this total also on the Statistical Summary of Certain Liabilities and
Related Data.

Check this box if debtor has no creditors holding unsecured claims to report on this Schedule F.

CREDITOR’S NAME,
MAILING ADDRESS

INCLUDING ZIP CODE,
AND ACCOUNT NUMBER

(See instructions above.)

R
O
T
B
E
D
O
C

T
N
I
O
J


,

E
F
I
W


,

D
N
A
B
S
U
H

Y
T
I
N
U
M
M
O
C
R
O

DATE CLAIM WAS INCURRED AND

CONSIDERATION FOR CLAIM.

IF CLAIM IS SUBJECT TO SETOFF,

SO STATE.

T
N
E
G
N
I
T
N
O
C

D
E
T
A
D
I
U
Q
I
L
N
U

D
E
T
U
P
S
I
D

AMOUNT

OF

CLAIM

0

.

3

e
g
n
a
h
C
X
-
F
D
P

-


0
1
1
1
0
-
X
1
0
3
-
1
3
1
2
3

-


4
7
7
-
7

.

6

.

4


.
r
e
v


,
.
c
n
I

,
e
r
a
w

t
f
o
S

e
p
o
H
w
e
N




,

Consideration: Revolving charge account

ACCOUNT NO.
Clayton County Tax Commissioner
Clayton County Administration, Annex
3
121 South McDonough Street
Jonesboro, GA 30236

ACCOUNT NO.
Ft McPherson CU
165 N. Main Street
Jonesboro, GA 30236-3568

Notice Only

8,833.00

Notice Only

Notice Only

8,833.00
8,833.00

Consideration: Account



2
1
0
2
-
1
9
9
1
©
2
1
0
2
y
c
t
p
u
r
k
n
a
B

ACCOUNT NO.
GMAC Mortgage, LLC
c/o McCurdy & Candler, LLC
Six Piedmont Center, Suite 700
3525 Piedmont Road, NE
Atlanta, GA 30305

ACCOUNT NO.
IRS
401 W Peachtree Street NW Suite 1400
Stop 1000-D
Atlanta, GA 30308-3539

_______continuation sheets attached

0

Subtotal $

Total
(Use only on last page of the completed Schedule F.)
(Report also on Summary of Schedules and, if applicable, on the Statistical
Summary of Certain Liabilities and Related Data.)

$

Case 12-61259-mgd Doc 1 Filed 04/30/12 Entered 04/30/12 19:11:58 Desc Main

B6G (Official Form 6G) (12/07)

Document Page 22 of 47

Tom Thomas

In re

Debtor

Case No.

(if known)

SCHEDULE G - EXECUTORY CONTRACTS AND UNEXPIRED LEASES

Describe all executory contracts of any nature and all unexpired leases of real or personal property. Include any timeshare interests.
State nature of debtor’s interest in contract, i.e., “Purchaser,” “Agent,” etc. State whether debtor is the lessor or lessee of a lease. Provide the
names and complete mailing addresses of all other parties to each lease or contract described. If a minor child is a party to one of the leases or
contracts, state the child's initials and the name and address of the child's parent or guardian, such as "A.B., a minor child, by John Doe,
guardian." Do not disclose the child’s name. See 11 U.S.C. § 112 and Fed. R. Bankr. P. 1007(m).

Check this box if debtor has no executory contracts or unexpired leases.

DESCRIPTION OF CONTRACT OR LEASE AND NATURE OF

DEBTOR’S INTEREST. STATE WHETHER LEASE IS FOR
NONRESIDENTIAL REAL PROPERTY. STATE CONTRACT

NUMBER OF ANY GOVERNMENT CONTRACT.

NAME AND MAILING ADDRESS, INCLUDING ZIP CODE,

OF OTHER PARTIES TO LEASE OR CONTRACT.

0

.

3

e
g
n
a
h
C
X
-
F
D
P

-


0
1
1
1
0
-
X
1
0
3
-
1
3
1
2
3

-


4
7
7
-
7

.

6

.

4


.
r
e
v


,
.
c
n
I

,
e
r
a
w

t
f
o
S

e
p
o
H
w
e
N




,



2
1
0
2
-
1
9
9
1
©
2
1
0
2
y
c
t
p
u
r
k
n
a
B

Case 12-61259-mgd Doc 1 Filed 04/30/12 Entered 04/30/12 19:11:58 Desc Main

B6H (Official Form 6H) (12/07)

Document Page 23 of 47

In re

Tom Thomas

Debtor

Case No.

(if known)

SCHEDULE H - CODEBTORS

Provide the information requested concerning any person or entity, other than a spouse in a joint case, that is also liable on any

debts listed by debtor in the schedules of creditors. Include all guarantors and co-signers. If the debtor resides or resided in a community
property state, commonwealth, or territory (including Alaska, Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Puerto Rico,
Texas, Washington, or Wisconsin) within the eight year period immediately preceding the commencement of the case, identify the
name of the debtor’s spouse and of any former spouse who resides or resided with the debtor in the community property state,
commonwealth, or territory. Include all names used by the nondebtor spouse during the eight years immediately preceding the
commencement of this case. If a minor child is a codebtor or a creditor, state the child's initials and the name and address of the child's
parent or guardian, such as "A.B., a minor child, by John Doe, guardian." Do not disclose the child's name. See 11 U.S.C. § 112 and
Fed. Bankr. P. 1007(m).

Check this box if debtor has no codebtors.

NAME AND ADDRESS OF CODEBTOR

NAME AND ADDRESS OF CREDITOR

Patsy Thomas
5603 Old Orchard Court
Rex, GA 30273

Patsy Thomas
5603 Old Orchard Court
Rex, GA 30273

Patsy Thomas
5603 Old Orchard Court
Rex, GA 30273

Patsy Thomas
5603 Old Orchard Court
Rex, GA 30273

IRS
Arcadia
Ft. McPherson CU
Homecomings

Arcadia Financial
P.O. Box 1472
Minneapolis, MN 55440-1472

Clayton County Tax Comm
121 S. McDonough St.
Courthouse Annex
Jonesboro, GA 30236

Homecomings
c/o Morris Schneider and Prior
1587 Northeast Expressway
Atlanta, GA 30329

0

.

3

e
g
n
a
h
C
X
-
F
D
P

-


0
1
1
1
0
-
X
1
0
3
-
1
3
1
2
3

-


4
7
7
-
7

.

6

.

4


.
r
e
v


,
.
c
n
I

,
e
r
a
w

t
f
o
S

e
p
o
H
w
e
N




,



2
1
0
2
-
1
9
9
1
©
2
1
0
2
y
c
t
p
u
r
k
n
a
B

Case 12-61259-mgd Doc 1 Filed 04/30/12 Entered 04/30/12 19:11:58 Desc Main

Document Page 24 of 47

B6I (Official Form 6I) (12/07)

Tom Thomas

In re

Debtor
SCHEDULE I - CURRENT INCOME OF INDIVIDUAL DEBTOR(S)

(if known)

The column labeled "Spouse" must be completed in all cases filed by joint debtors and by every married debtor, whether or not a joint petition is
filed, unless the spouses are separated and a joint petition is not filed. Do not state the name of any minor child. The average monthly income
calculated on this form may differ from the current monthly income calculated on Form 22A, 22B, or 22C.

Case

Debtor’s Marital
Status:

Married

Employment:
Occupation
Name of Employer
How long employed
Address of Employer

DEPENDENTS OF DEBTOR AND SPOUSE

RELATIONSHIP(S):

No dependents

DEBTOR

Staff
Northern Tool and Equipment
3.5 years
2800 Southcross Drive
Burnville, MN 55337

AGE(S):

SPOUSE

Selective HR Solutions

Atlanta, GA

INCOME: (Estimate of average or projected monthly income at time case filed)
1. Monthly gross wages, salary, and commissions

(Prorate if not paid monthly.)

2. Estimated monthly overtime
3. SUBTOTAL
4. LESS PAYROLL DEDUCTIONS

a. Payroll taxes and social security
b. Insurance
c. Union Dues
d. Other (Specify:___________________________________________________________)

5. SUBTOTAL OF PAYROLL DEDUCTIONS
6.. TOTAL NET MONTHLY TAKE HOME PAY

7. Regular income from operation of business or profession or farm
(Attach detailed statement)
8. Income from real property
9. Interest and dividends
10. Alimony, maintenance or support payments payable to the debtor for the
debtor’s use or that of dependents listed above.
11. Social security or other government assistance
( Specify)
12. Pension or retirement income
13. Other monthly income
(Specify)
14. SUBTOTAL OF LINES 7 THROUGH 13

15. AVERAGE MONTHLY INCOME (Add amounts shown on Lines 6 and 14)

16. COMBINED AVERAGE MONTHLY INCOME (Combine column totals
from line 15)

DEBTOR SPOUSE

$ _____________ $ _____________

$ _____________ $ _____________

$ _____________ $ _____________

1,713.00
0.00
1,713.00

1,941.00
0.00
1,941.00

$ _____________ $ _____________
$ _____________ $ _____________
$ _____________ $ _____________
$ _____________ $ _____________

393.00
103.00
0.00
0.00

625.00
0.00
0.00
0.00

$ _____________ $ _____________

$ _____________ $ _____________

625.00
1,316.00

496.00
1,217.00

$ _____________ $ _____________

0.00

0.00

$ _____________ $ _____________
$ _____________ $ _____________

0.00
0.00

0.00
0.00

$ _____________ $ _____________

0.00

0.00

$ _____________ $ _____________

0.00

0.00

$ _____________ $ _____________
$ _____________ $ _____________
$ _____________ $ _____________
$ _____________ $ _____________

1,116.00
0.00
0.00
1,116.00
2,333.00

0.00
0.00
0.00
0.00
1,316.00

$ _____________ $ _____________

3,649.00
$ _____________

(Report also on Summary of Schedules and, if applicable,
on Statistical Summary of Certain Liabilities and Related Data)

17. Describe any increase or decrease in income reasonably anticipated to occur within the year following the filing of this document:

None

0

.

3

e
g
n
a
h
C
X
-
F
D
P

-


0
1
1
1
0
-
X
1
0
3
-
1
3
1
2
3

-


4
7
7
-
7

.

6

.

4


.
r
e
v


,
.
c
n
I

,
e
r
a
w

t
f
o
S

e
p
o
H
w
e
N




,



2
1
0
2
-
1
9
9
1
©
2
1
0
2
y
c
t
p
u
r
k
n
a
B

B6J (Official Form 6J) (12/07)

Case 12-61259-mgd Doc 1 Filed 04/30/12 Entered 04/30/12 19:11:58 Desc Main

Document Page 25 of 47

In re

Tom Thomas

Debtor

Case No.

(if known)

SCHEDULE J - CURRENT EXPENDITURES OF INDIVIDUAL DEBTOR(S)
Complete this schedule by estimating the average or projected monthly expenses of the debtor and the debtor’s family at time case

filed. Prorate any payments made biweekly, quarterly, semi-annually, or annually to show monthly rate. The average monthly expenses
calculated on this form may differ from the deductions from income allowed on Form 22A or 22C.

Check this box if a joint petition is filed and debtor’s spouse maintains a separate household. Complete a separate schedule of expenditures
labeled “Spouse.”

1. Rent or home mortgage payment (include lot rented for mobile home)

a. Are real estate taxes included?
b. Is property insurance included?

2. Utilities: a. Electricity and heating fuel

b. Water and sewer

Yes ________ No ________
Yes ________ No ________

c. Telephone
Cell
d. Other ___________________________________________________________________

3. Home maintenance (repairs and upkeep)
4. Food
5. Clothing
6. Laundry and dry cleaning
7. Medical and dental expenses
8. Transportation (not including car payments)
9. Recreation, clubs and entertainment, newspapers, magazines, etc.
10.Charitable contributions
11.Insurance (not deducted from wages or included in home mortgage payments)

a. Homeowner’s or renter’s
b. Life
c. Health
d.Auto
e. Other

12.Taxes (not deducted from wages or included in home mortgage payments)
(Specify)
13. Installment payments: (In chapter 11, 12, and 13 cases, do not list payments to be included in the plan)

a. Auto
b. Other
c. Other

14. Alimony, maintenance, and support paid to others
15. Payments for support of additional dependents not living at your home
16. Regular expenses from operation of business, profession, or farm (attach detailed statement)
17. Other
18. AVERAGE MONTHLY EXPENSES (Total lines 1-17. Report also on Summary of Schedules and,
if applicable, on the Statistical Summary of Certain Liabilities and Related Data)
19. Describe any increase or decrease in expenditures reasonably anticipated to occur within the year following the filing of this document:

$ _____________
1,500.00

$ ______________
254.00
$ ______________
60.00
$ ______________
130.00
$ ______________
70.00
$ ______________
70.00
$ ______________
350.00
$ ______________
85.00
$ ______________
0.00
$ ______________
100.00
$ ______________
420.00
$ ______________
0.00
$ ______________
0.00

$ ______________
0.00
$ ______________
0.00
$ ______________
0.00
$ ______________
230.00
$ ______________
0.00

$ ______________
0.00

$______________
0.00
$ ______________
0.00
$ ______________
0.00
$ ______________
0.00
$ ______________
0.00
$ ______________
0.00
$______________
0.00
$______________
3,269.00

None

20. STATEMENT OF MONTHLY NET INCOME

a. Average monthly income from Line 15 of Schedule I
b. Average monthly expenses from Line 18 above
c. Monthly net income (a. minus b.)

(Includes spouse income of $1,316.00. See Schedule I)

(Net includes Debtor/Spouse combined Amounts)

3,649.00
$ ______________
$ ______________
3,269.00
380.00
$ ______________

0

.

3

e
g
n
a
h
C
X
-
F
D
P

-


0
1
1
1
0
-
X
1
0
3
-
1
3
1
2
3

-


4
7
7
-
7

.

6

.

4


.
r
e
v


,
.
c
n
I

,
e
r
a
w

t
f
o
S

e
p
o
H
w
e
N




,



2
1
0
2
-
1
9
9
1
©
2
1
0
2
y
c
t
p
u
r
k
n
a
B

Case 12-61259-mgd Doc 1 Filed 04/30/12 Entered 04/30/12 19:11:58 Desc Main

B7 (Official Form 7) (04/10)

UNITED STATES BANKRUPTCY COURT

Document Page 26 of 47
Northern District of Georgia

In Re

Tom Thomas

Case No.

(if known)

STATEMENT OF FINANCIAL AFFAIRS

This statement is to be completed by every debtor. Spouses filing a joint petition may file a single statement on which
the information for both spouses is combined. If the case is filed under chapter 12 or chapter 13, a married debtor must furnish
information for both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not
filed. An individual debtor engaged in business as a sole proprietor, partner, family farmer, or self-employed professional, should
provide the information requested on this statement concerning all such activities as well as the individual's personal affairs. To
indicate payments, transfers and the like to minor children, state the child's initials and the name and address of the child's parent
or guardian, such as "A.B., a minor child, by John Doe, guardian." Do not disclose the child's name. See 11 U.S.C. § 112 and Fed.
R. Bankr. P. 1007(m).

Questions 1 - 18 are to be completed by all debtors. Debtors that are or have been in business, as defined below, also

must complete Questions 19 - 25. If the answer to an applicable question is "None," mark the box labeled "None." If
additional space is needed for the answer to any question, use and attach a separate sheet properly identified with the case name,
case number (if known), and the number of the question.

DEFINITIONS

"In business." A debtor is "in business" for the purpose of this form if the debtor is a corporation or partnership. An

individual debtor is "in business" for the purpose of this form if the debtor is or has been, within six years immediately preceding
the filing of this bankruptcy case, any of the following: an officer, director, managing executive, or owner of 5 percent or more of
the voting or equity securities of a corporation; a partner, other than a limited partner, of a partnership; a sole proprietor or self-
employed full-time or part-time. An individual debtor also may be “in business” for the purpose of this form if the debtor engages
in a trade, business, or other activity, other than as an employee, to supplement income from the debtor’s primary employment.

"Insider." The term "insider" includes but is not limited to: relatives of the debtor; general partners of the debtor and

their relatives; corporations of which the debtor is an officer, director, or person in control; officers, directors, and any owner of 5
percent or more of the voting or equity securities of a corporate debtor and their relatives; affiliates of the debtor and insiders of
such affiliates; any managing agent of the debtor. 11 U.S.C. § 101.

1. Income from employment or operation of business

None

State the gross amount of income the debtor has received from employment, trade, or profession, or from operation of
the debtor's business, including part-time activities either as an employee or in independent trade or business, from the
beginning of this calendar year to the date this case was commenced. State also the gross amounts received during the
two years immediately preceding this calendar year. (A debtor that maintains, or has maintained, financial records on
the basis of a fiscal rather than a calendar year may report fiscal year income. Identify the beginning and ending dates
of the debtor's fiscal year.) If a joint petition is filed, state income for each spouse separately. (Married debtors filing
under chapter 12 or chapter 13 must state income of both spouses whether or not a joint petition is filed, unless the
spouses are separated and a joint petition is not filed.)

SOURCE

2012(db)

2011(db)

AMOUNT
8456

34000

2010(db)

31,943.00

2007(nfs)

2006(nfs)

2005(nfs)

0

.

3

e
g
n
a
h
C
X
-
F
D
P

-


0
1
1
1
0
-
X
1
0
3
-
1
3
1
2
3

-


4
7
7
-
7

.

6

.

4


.
r
e
v


,
.
c
n
I

,
e
r
a
w

t
f
o
S

e
p
o
H
w
e
N




,



2
1
0
2
-
1
9
9
1
©
2
1
0
2
y
c
t
p
u
r
k
n
a
B

Case 12-61259-mgd Doc 1 Filed 04/30/12 Entered 04/30/12 19:11:58 Desc Main

Document Page 27 of 47

2. Income other than from employment or operation of business

None

State the amount of income received by the debtor other than from employment, trade, profession, or operation
of the debtor's business during the two years immediately preceding the commencement of this case. Give
particulars. If a joint petition is filed, state income for each spouse separately. (Married debtors filing under chapter
12 or chapter 13 must state income for each spouse whether or not a joint petition is filed, unless the spouses are
separated and a joint petition is not filed.)

AMOUNT

SOURCE

None

3. Payments to creditors

Complete a. or b., as appropriate, and c.
a. Individual or joint debtor(s) with primarily consumer debts: List all payments on loans, installment purchases of
goods or services, and other debts to any creditor made within 90 days immediately preceding the commencement of
this case unless the aggregate value of all property that constitutes or is affected by such transfer is less than $600.
Indicate with an asterisk (*) any payments that were made to a creditor on account of a domestic support obligation
or as part of an alternative repayment schedule under a plan by an approved nonprofit budgeting and creditor
counseling agency. (Married debtors filing under chapter 12 or chapter 13 must include payments by either or both
spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.)

NAME AND ADDRESS OF CREDITOR

DATES OF
PAYMENTS

AMOUNT

PAID

AMOUNT STILL

OWING

None

b. Debtor whose debts are not primarily consumer debts: List each payment or other transfer to any creditor made
within 90 days immediately preceding the commencement of the case unless the aggregate value of all property that
constitutes or is affected by such transfer is less than $5,850*. If the debtor is an individual, indicate with an asterisk
(*)(cid:0)any payments that were made to a creditor on account of a domestic support obligation or as part of an
alternative(cid:0)repayment schedule under a plan by an approved nonprofit budgeting and credit counseling agency.
(Married debtors filing under chapter 12 or chapter 13 must include payments and other transfers by either or both
spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.)

*Amount subject to adjustment on 4/01/13, and every three years thereafter with respect to cases commenced on or after date of adjustment.
NAME AND ADDRESS OF CREDITOR

AMOUNT

AMOUNT STILL

DATES OF
PAYMENTS

AND RELATIONSHIP TO DEBTOR

PAID

OWING

0

.

3

e
g
n
a
h
C
X
-
F
D
P

-


0
1
1
1
0
-
X
1
0
3
-
1
3
1
2
3

-


4
7
7
-
7

.

6

.

4


.
r
e
v


,
.
c
n
I

,
e
r
a
w

t
f
o
S

e
p
o
H
w
e
N




,



2
1
0
2
-
1
9
9
1
©
2
1
0
2
y
c
t
p
u
r
k
n
a
B

Case 12-61259-mgd Doc 1 Filed 04/30/12 Entered 04/30/12 19:11:58 Desc Main

Document Page 28 of 47

None

c. All debtors: List all payments made within one year immediately preceding the commencement of this case to or
for the benefit of creditors who are or were insiders. (Married debtors filing under chapter 12 or chapter 13 must
include payments by either or both spouses whether or not a joint petition is filed, unless the spouses are separated
and a joint petition is not filed.)

NAME AND ADDRESS OF CREDITOR

AND RELATIONSHIP TO DEBTOR

DATES OF
PAYMENTS

AMOUNT PAID

AMOUNT STILL

OWING

4. Suits and administrative proceedings, executions, garnishments and attachments

None

a. List all suits and administrative proceedings to which the debtor is or was a party within one year immediately
preceding the filing of this bankruptcy case. (Married debtors filing under chapter 12 or chapter 13 must include
information concerning either or both spouses whether or not a joint petition is filed, unless the spouses are separated
and a joint petition is not filed.)

NATURE OF PROCEEDING

COURT OR

AGENCY AND LOCATION

STATUS OR
DISPOSITION

CAPTION OF SUIT
AND CASE NUMBER

Ft McPherson CU
obtained a judgment
against the Debtor.

None

b. Describe all property that has been attached, garnished or seized under any legal or equitable process within
one year immediately preceding the commencement of this case. (Married debtors filing under chapter 12 or chapter
13 must include information concerning property of either or both spouses whether or not a joint petition is filed,
unless the spouses are separated and a joint petition is not filed.)

NAME AND ADDRESS OF

PERSON FOR WHOSE BENEFIT

PROPERTY WAS SEIZED

DATE OF
SEIZURE

DESCRIPTION AND

VALUE OF PROPERTY

5. Repossessions, foreclosures and returns

None

List all property that has been repossessed by a creditor, sold at a foreclosure sale, transferred through a deed in
lieu of foreclosure or returned to the seller, within one year immediately preceding the commencement of this case.
(Married debtors filing under chapter 12 or chapter 13 must include information concerning property of either or
both spouses whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.)

NAME AND
ADDRESS OF

CREDITOR OR SELLER

DATE OF REPOSESSION,
FORECLOSURE SALE,
TRANSFER OR RETURN

DESCRIPTION AND

VALUE OF PROPERTY

American Financial Services
PO Box 307
Forest Park, GA 30298

April 2012

2000 Cadillac DeVille

0

.

3

e
g
n
a
h
C
X
-
F
D
P

-


0
1
1
1
0
-
X
1
0
3
-
1
3
1
2
3

-


4
7
7
-
7

.

6

.

4


.
r
e
v


,
.
c
n
I

,
e
r
a
w

t
f
o
S

e
p
o
H
w
e
N




,



2
1
0
2
-
1
9
9
1
©
2
1
0
2
y
c
t
p
u
r
k
n
a
B

Case 12-61259-mgd Doc 1 Filed 04/30/12 Entered 04/30/12 19:11:58 Desc Main

Document Page 29 of 47

6. Assignments and Receiverships

None

a. Describe any assignment of property for the benefit of creditors made within 120 days immediately preceding
the commencement of this case. (Married debtors filing under chapter 12 or chapter 13 must include any
assignment by either or both spouses whether or not a joint petition is filed, unless the spouses are separated and a
joint petition is not filed.)

NAME AND
ADDRESS OF
ASSIGNEE

DATE OF ASSIGNMENT

TERMS OF

ASSIGNMENT

OR SETTLEMENT

None

b. List all property which has been in the hands of a custodian, receiver, or court-appointed official within one
year immediately preceding the commencement of this case. (Married debtors filing under chapter 12 or chapter 13
must include information concerning property of either or both spouses whether or not a joint petition is filed, unless
the spouses are separated and a joint petition is not filed.)

NAME AND LOCATION
OF COURT CASE TITLE

& NUMBER

DATE OF
ORDER

DESCRIPTION AND

VALUE OF PROPERTY

NAME AND
ADDRESS OF
CUSTODIAN

7. Gifts

None

List all gifts or charitable contributions made within one year immediately preceding the commencement of this
case, except ordinary and usual gifts to family members aggregating less than $200 in value per individual family
member and charitable contributions aggregating less than $100 per recipient. (Married debtors filing under chapter
12 or chapter 13 must include gifts or contributions by either or both spouses whether or not a joint petition is filed,
unless the spouses are separated and a joint petition is not filed.)

NAME AND
ADDRESS OF

PERSON OR ORGANIZATION

8. Losses

RELATIONSHIP

TO DEBTOR, IF ANY

DATE OF

GIFT

DESCRIPTION AND

VALUE OF GIFT

None

List all losses from fire, theft, other casualty or gambling within one year immediately preceding the
commencement of this case or since the commencement of this case. (Married debtors filing under chapter 12 or
chapter 13 must include losses by either or both spouses whether or not a joint petition is filed, unless the spouses are
separated and a joint petition is not filed.)

DESCRIPTION
AND VALUE
OF PROPERTY

DESCRIPTION OF CIRCUMSTANCES, AND, IF LOSS

WAS COVERED IN WHOLE OR IN PART BY

INSURANCE, GIVE PARTICULARS

DATE OF

LOSS

0

.

3

e
g
n
a
h
C
X
-
F
D
P

-


0
1
1
1
0
-
X
1
0
3
-
1
3
1
2
3

-


4
7
7
-
7

.

6

.

4


.
r
e
v


,
.
c
n
I

,
e
r
a
w

t
f
o
S

e
p
o
H
w
e
N




,



2
1
0
2
-
1
9
9
1
©
2
1
0
2
y
c
t
p
u
r
k
n
a
B

Case 12-61259-mgd Doc 1 Filed 04/30/12 Entered 04/30/12 19:11:58 Desc Main

Document Page 30 of 47

9. Payments related to debt counseling or bankruptcy

None

List all payments made or property transferred by or on behalf of the debtor to any persons, including attorneys,
for consultation concerning debt consolidation, relief under the bankruptcy law or preparation of a petition in
bankruptcy within one year immediately preceding the commencement of this case.

AMOUNT OF MONEY OR

DESCRIPTION AND

VALUE OF PROPERTY

NAME AND ADDRESS

OF PAYEE

DATE OF PAYMENT,
NAME OF PAYOR IF

OTHER THAN DEBTOR

Joseph Chad Brannen
Brannen Law Group, PC
7147 Jonesboro Rd.
Suite G
Morrow, GA 30260

Incharge

10. Other transfers

4-12

4-12

281

16

None

a. List all other property, other than property transferred in the ordinary course of the business or financial affairs
of the debtor, transferred either absolutely or as security within two years immediately preceding the commencement
of this case. (Married debtors filing under chapter 12 or chapter 13 must include transfers by either or both spouses
whether or not a joint petition is filed, unless the spouses are separated and a joint petition is not filed.)

NAME AND ADDRESS OF TRANSFEREE,

RELATIONSHIP TO DEBTOR

DATE

DESCRIBE PROPERTY
TRANSFERRED AND
VALUE RECEIVED

b. List all property transferred by the debtor within ten years immediately preceding the commencement of this case
to a self-settled trust or similar device of which the debtor is a beneficiary.

None

NAME OF TRUST OR OTHER DEVICE

DATE(S) OF
TRANSFER(S)

AMOUNT OF MONEY OR

DESCRIPTION AND

VALUE OF PROPERTY OR

DEBTOR'S INTEREST IN PROPERTY

0

.

3

e
g
n
a
h
C
X
-
F
D
P

-


0
1
1
1
0
-
X
1
0
3
-
1
3
1
2
3

-


4
7
7
-
7

.

6

.

4


.
r
e
v


,
.
c
n
I

,
e
r
a
w

t
f
o
S

e
p
o
H
w
e
N




,



2
1
0
2
-
1
9
9
1
©
2
1
0
2
y
c
t
p
u
r
k
n
a
B

Case 12-61259-mgd Doc 1 Filed 04/30/12 Entered 04/30/12 19:11:58 Desc Main

Document Page 31 of 47

11. Closed financial accounts

None

List all financial accounts and instruments held in the name of the debtor or for the benefit of the debtor which
were closed, sold, or otherwise transferred within one year immediately preceding the commencement of this case.
Include checking, savings, or other financial accounts, certificates of deposit, or other instruments; shares and share
accounts held in banks, credit unions, pension funds, cooperatives, associations, brokerage houses and other financial
institutions. (Married debtors filing under chapter 12 or chapter 13 must include information concerning accounts or
instruments held by either or both spouses whether or not a joint petition is filed, unless the spouses are separated
and a joint petition is not filed.)

NAME AND
ADDRESS OF
INSTITUTION

TYPE OF ACCOUNT, LAST FOUR
DIGITS OF ACCOUNT NUMBER,

AND AMOUNT OF FINAL BALANCE

AMOUNT AND
DATE OF SALE
OR CLOSING

12. Safe deposit boxes

None

List each safe deposit or other box or depository in which the debtor has or had securities, cash, or other
valuables within one year immediately preceding the commencement of this case. (Married debtors filing under
chapter 12 or chapter 13 must include boxes or depositories of either or both spouses whether or not a joint petition
is filed, unless the spouses are separated and a joint petition is not filed.)

NAME AND

ADDRESS OF BANK

OR OTHER DEPOSITORY

NAMES AND ADDRESSES OF
THOSE WITH ACCESS TO BOX

OR DEPOSITORY

DESCRIPTION OF

CONTENTS

DATE OF

TRANSFER OR

SURRENDER, IF ANY

13. Setoffs

None

List all setoffs made by any creditor, including a bank, against a debt or deposit of the debtor within 90 days
preceding the commencement of this case. (Married debtors filing under chapter 12 or chapter 13 must include
information concerning either or both spouses whether or not a joint petition is filed, unless the spouses are separated
and a joint petition is not filed.)

NAME AND ADDRESS OF CREDITOR

DATE
OF

SETOFF

14. Property held for another person

None

List all property owned by another person that the debtor holds or controls.

AMOUNT

OF

SETOFF

NAME AND

ADDRESS OF OWNER

DESCRIPTION AND

VALUE OF PROPERTY

LOCATION OF PROPERTY

0

.

3

e
g
n
a
h
C
X
-
F
D
P

-


0
1
1
1
0
-
X
1
0
3
-
1
3
1
2
3

-


4
7
7
-
7

.

6

.

4


.
r
e
v


,
.
c
n
I

,
e
r
a
w

t
f
o
S

e
p
o
H
w
e
N




,



2
1
0
2
-
1
9
9
1
©
2
1
0
2
y
c
t
p
u
r
k
n
a
B

Case 12-61259-mgd Doc 1 Filed 04/30/12 Entered 04/30/12 19:11:58 Desc Main

Document Page 32 of 47

None

None

None

None

15. Prior address of debtor

If the debtor has moved within the three years immediately preceding the commencement of this case, list all
premises which the debtor occupied during that period and vacated prior to the commencement of this case. If a
joint petition is filed, report also any separate address of either spouse.

ADDRESS

NAME USED

DATES OF OCCUPANCY

16. Spouses and Former Spouses

If the debtor resides or resided in a community property state, commonwealth, or territory (including Alaska,
Arizona, California, Idaho, Louisiana, Nevada, New Mexico, Puerto Rico, Texas, Washington, or Wisconsin) within
eight years immediately preceding the commencement of the case, identify the name of the debtor’s spouse and of
any former spouse who resides or resided with the debtor in the community property state.

NAME

17. Environmental Sites

For the purpose of this question, the following definitions apply:

"Environmental Law" means any federal, state, or local statute or regulation regulating pollution, contamination,
releases of hazardous or toxic substances, wastes or material into the air, land, soil, surface water, groundwater, or
other medium, including, but not limited to, statutes or regulations regulating the cleanup of these substances,
wastes, or material.

"Site" means any location, facility, or property as defined under any Environmental Law, whether or not
presently or formerly owned or operated by the debtor, including, but not limited to, disposal sites.

"Hazardous Material" means anything defined as a hazardous waste, hazardous substance, toxic substance,
hazardous material, pollutant, or contaminant or similar term under an Environmental Law

a. List the name and address of every site for which the debtor has received notice in writing by a governmental
unit that it may be liable or potentially liable under or in violation of an Environmental Law. Indicate the
governmental unit, the date of the notice, and, if known, the Environmental Law:

SITE NAME

AND ADDRESS

NAME AND ADDRESS

OF GOVERNMENTAL UNIT

DATE OF
NOTICE

ENVIRONMENTAL

LAW

b. List the name and address of every site for which the debtor provided notice to a governmental unit of a release
of Hazardous Material. Indicate the governmental unit to which the notice was sent and the date of the notice.

SITE NAME

AND ADDRESS

NAME AND ADDRESS

OF GOVERNMENTAL UNIT

DATE OF
NOTICE

ENVIRONMENTAL

LAW

0

.

3

e
g
n
a
h
C
X
-
F
D
P

-


0
1
1
1
0
-
X
1
0
3
-
1
3
1
2
3

-


4
7
7
-
7

.

6

.

4


.
r
e
v


,
.
c
n
I

,
e
r
a
w

t
f
o
S

e
p
o
H
w
e
N




,



2
1
0
2
-
1
9
9
1
©
2
1
0
2
y
c
t
p
u
r
k
n
a
B

Case 12-61259-mgd Doc 1 Filed 04/30/12 Entered 04/30/12 19:11:58 Desc Main

Document Page 33 of 47

c. List all judicial or administrative proceedings, including settlements or orders, under any Environmental Law
with respect to which the debtor is or was a party. Indicate the name and address of the governmental unit that is or
was a party to the proceeding, and the docket number.

None

NAME AND ADDRESS

OF GOVERNMENTAL UNIT

18. Nature, location and name of business

DOCKET NUMBER

STATUS OR DISPOSITION

None

a. If the debtor is an individual, list the names, addresses, taxpayer identification numbers, nature of the
businesses, and beginning and ending dates of all businesses in which the debtor was an officer, director, partner, or
managing executive of a corporation, partnership, sole proprietorship, or was self-employed in a trade, profession, or
other activity either full- or part-time within six years immediately preceding the commencement of this case, or in
which the debtor owned 5 percent or more of the voting or equity securities within the six years immediately
preceding the commencement of this case.

If the debtor is a partnership, list the names, addresses, taxpayer identification numbers, nature of the businesses, and
beginning and ending dates of all businesses in which the debtor was a partner or owned 5 percent or more of the
voting or equity securities, within the six years immediately preceding the commencement of this case.

If the debtor is a corporation, list the names, addresses, taxpayer identification numbers, nature of the businesses, and
beginning and ending dates of all businesses in which the debtor was a partner or owned 5 percent or more of the
voting or equity securities within the six years immediately preceding the commencement of this case.

NAME

LAST FOUR DIGITS OF
SOCIAL-SECURITY OR
OTHER INDIVIDUAL
TAXPAYER-I.D. NO.
(ITIN)/ COMPLETE EIN

ADDRESS

NATURE OF BUSINESS BEGINNING AND
ENDING DATES

b. Identify any business listed in response to subdivision a., above, that is "single asset real estate" as defined in 11
U.S.C. § 101.

None

NAME

ADDRESS

[Questions 19 - 25 are not applicable to this case]

* * * * * *

0

.

3

e
g
n
a
h
C
X
-
F
D
P

-


0
1
1
1
0
-
X
1
0
3
-
1
3
1
2
3

-


4
7
7
-
7

.

6

.

4


.
r
e
v


,
.
c
n
I

,
e
r
a
w

t
f
o
S

e
p
o
H
w
e
N




,



2
1
0
2
-
1
9
9
1
©
2
1
0
2
y
c
t
p
u
r
k
n
a
B

Case 12-61259-mgd Doc 1 Filed 04/30/12 Entered 04/30/12 19:11:58 Desc Main

Document Page 34 of 47

[If completed by an individual or individual and spouse]

I declare under penalty of perjury that I have read the answers contained in the foregoing statement of financial affairs and any attachments
thereto and that they are true and correct.
4-30-12

Signature
of Debtor

/s/ Tom Thomas
TOM THOMAS

Date

0

_____ continuation sheets attached

Penalty for making a false statement: Fine of up to $500,000 or imprisonment for up to 5 years, or both. 18 U.S.C. §152 and 3571

DECLARATION AND SIGNATURE OF NON-ATTORNEY BANKRUPTCY PETITION PREPARER (See 11 U.S.C. § 110)
I declare under penalty of perjury that: (1) I am a bankruptcy petition preparer as defined in 11 U.S.C. § 110; (2) I prepared this document for
compensation and have provided the debtor with a copy of this document and the notices and required under 11U.S.C. §§ 110(b), 110(h), and 342(b); (3) if
rules or guidelines have been promulgated pursuant to 11 U.S.C. § 110 setting a maximum fee for services chargeable by bankruptcy petition preparers, I
have given the debtor notice of the maximum amount before preparing any document for filing for a debtor or accepting any fee from the debtor, as required
in that section.

Printed or Typed Name and Title, if any, of Bankruptcy Petition Preparer
Social Security No. (Required by 11 U.S.C. § 110(c).)
If the bankruptcy petition preparer is not an individual, state the name, title (if any), address, and social security number of the officer, principal, responsible person, or
partner who signs this document.

Address

X
Signature of Bankruptcy Petition Preparer

Date

Names and Social Security numbers of all other individuals who prepared or assisted in preparing this document unless the bankruptcy petition preparer is
not an individual:

If more than one person prepared this document, attach additional signed sheets conforming to the appropriate Official Form for each person.

A bankruptcy petition preparer's failure to comply with the provisions of title 11 and the Federal Rules of Bankruptcy Procedure may result in fines
or imprisonment or both. 18 U.S.C. §156.

0

.

3

e
g
n
a
h
C
X
-
F
D
P

-


0
1
1
1
0
-
X
1
0
3
-
1
3
1
2
3

-


4
7
7
-
7

.

6

.

4


.
r
e
v


,
.
c
n
I

,
e
r
a
w

t
f
o
S

e
p
o
H
w
e
N




,



2
1
0
2
-
1
9
9
1
©
2
1
0
2
y
c
t
p
u
r
k
n
a
B

B203
12/94

Case 12-61259-mgd Doc 1 Filed 04/30/12 Entered 04/30/12 19:11:58 Desc Main

Document Page 35 of 47

United States Bankruptcy Court

Northern District of Georgia

In re

Tom Thomas

Debtor(s)

Case No. ____________________
Chapter ____________________

13

DISCLOSURE OF COMPENSATION OF ATTORNEY FOR DEBTOR

1. Pursuant to 11 U .S.C. § 329(a) and Fed. Bankr. P. 2016(b), I certify that I am the attorney for the above-named debtor(s)

and that compensation paid to me within one year before the filing of the petition in bankruptcy, or agreed to be paid to me, for services
rendered or to be rendered on behalf of the debtor(s) in contemplation of or in connection with the bankruptcy case is as follow s:

For legal services, I have agreed to accept .............................……………………….... $ ______________

Prior to the filing of this statement I have received ..........…………………................... $ ______________

3,500.00
0.00
3,500.00

Balance Due ......................................……………………………………….................... $ ______________

2. The source of compensation paid to me was:

Debtor

Other (specify)

3. The source of compensation to be paid to me is:

Debtor

Other (specify)

4. I have not agreed to share the above-disclosed compensation with any other person unless they are members and
associates of my law firm.

I have agreed to share the above-disclosed compensation with a other person or persons who are not members or associates
of my law firm. A copy of the agreement, together with a list of the names of the people sharing in the compensation, is attached.

5. In return for the above-disclosed fee, I have agreed to render legal service for all aspects of the bankruptcy case, including:

a. Analysis of the debtor's financial situation, and rendering advice to the debtor in determining whether to file a petition in bankruptcy;
b. Preparation and filing of any petition, schedules, statements of affairs and plan which may be required;
c. Representation of the debtor at the meeting of creditors and confirmation hearing, and any adjourned hearings thereof;
d. Representation of the debtor in adversary proceedings and other contested bankruptcy matters;
e. [Other provisions as needed]

The Debtor paid the filing fee. The Debtor received the rights and responsibilites statement.

0

.

3

e
g
n
a
h
C
X
-
F
D
P

-


0
1
1
1
0
-
X
1
0
3
-
1
3
1
2
3

-


4
7
7
-
7

.

6

.

4


.
r
e
v


,
.
c
n
I

,
e
r
a
w

t
f
o
S

e
p
o
H
w
e
N




,

6. By agreement with the debtor(s), the above-disclosed fee does not include the following services:



2
1
0
2
-
1
9
9
1
©
2
1
0
2
y
c
t
p
u
r
k
n
a
B

I certify that the foregoing is a complete statement of any agreement or arrangement for payment to me for representation of the
debtor(s) in the bankruptcy proceeding.

CERTIFICATION

4-30-12

/s/ Joseph Chad Brannen

____________________________________ __________________________________________________

Date Signature of Attorney

__________________________________________________
Name of law firm

Brannen Law Group, P.C.

Case 12-61259-mgd Doc 1 Filed 04/30/12 Entered 04/30/12 19:11:58 Desc Main

Document Page 36 of 47

B 201B (Form 201B) (12/09)

United States Bankruptcy Court

Northern District of Georgia

In re

Tom Thomas

Debtor

Case No.

(If known)

CERTIFICATION OF NOTICE TO CONSUMER DEBTOR(S)

UNDER § 342(b) OF THE BANKRUPTCY CODE

Certification of [Non-Attorney] Bankruptcy Petition Preparer

I, the [non-attorney] bankruptcy petition preparer signing the debtor's petition, hereby certify that I delivered to the

debtor the attached notice, as required by § 342(b) of the Bankruptcy Code

Printed name and title, if any, of Bankruptcy Petition Preparer
Address:

X
Signature of Bankruptcy Petition Preparer or officer,
Principal, responsible person, or partner whose Social
Security number is provided above.

0

.

3

e
g
n
a
h
C
X
-
F
D
P

-


0
1
1
1
0
-
X
1
0
3
-
1
3
1
2
3

-


4
7
7
-
7

.

6

.

Social Security number (If the bankruptcy petition
preparer is not an individual, state the Social Security
number of the officer, principal, responsible person,
or partner of the bankruptcy petition preparer.)
(Required by 11 U.S.C. § 110.)

4


.
r
e
v


,
.
c
n
I

,
e
r
a
w

t
f
o
S

e
p
o
H
w
e
N




,



2
1
0
2
-
1
9
9
1
©
2
1
0
2
y
c
t
p
u
r
k
n
a
B

I, (We), the debtor(s), affirm that I (we) have received and read the attached notice, as required by § 342(b) of the Bankruptcy

Code

Certification of the Debtor

Tom Thomas
Printed Names(s) of Debtor(s)

Case No. (if known)

X

X

/s/ Tom Thomas
Signature of Debtor Date

4-30-12

Signature of Joint Debtor, (if any) Date

Instructions: Attach a copy of Form B 201A, Notice to Consumer Debtor(s) Under § 342(b) of the Bankruptcy Code.

Use this form to certify that the debtor has received the notice required by 11 U.S.C. § 342(b) only if the certification has
NOT been made on the Voluntary Petition, Official Form B1. Exhibit B on page 2 of Form B1 contains a certification by
the debtor's attorney that the attorney has given the notice to the debtor. The Declarations made by debtors and bankruptcy
petition preparers on page 3 of Form B1 also include this certification.

Case 12-61259-mgd Doc 1 Filed 04/30/12 Entered 04/30/12 19:11:58 Desc Main

Document Page 37 of 47

American Financial Services
PO Box 307
Forest Park, GA 30298

Clayton County Tax Commissioner
Clayton County Administration, Annex 3
121 South McDonough Street
Jonesboro, GA 30236

Covington Credit-Ga12
3859 Hwy 138 SE
Stockbridge, GA 30281

Fort McPherson Credit Union
c/o Charles Gisler, Esq.
165 North Main Street
Jonesboro, GA 30236-3568

Ft McPherson CU
165 N. Main Street
Jonesboro, GA 30236-3568

GMAC Mortgage, LLC
c/o McCurdy & Candler, LLC
Sidney Gelernter
3525 Piedmont Road NE, Bldg. 6, Ste. 700
Atlanta, GA 30305

GMAC Mortgage, LLC
c/o McCurdy & Candler, LLC
Six Piedmont Center, Suite 700
3525 Piedmont Road, NE
Atlanta, GA 30305

Internal Revenue Service, Insolvency
Room 400 Stop 334-D
401 West Peachtree Street
Atlanta, GA 30308

IRS
401 W Peachtree Street NW Suite 1400
Stop 1000-D
Atlanta, GA 30308-3539

Case 12-61259-mgd Doc 1 Filed 04/30/12 Entered 04/30/12 19:11:58 Desc Main

Document Page 38 of 47

IRS, Insolvency Section
PO Box 21126
Philadelphia, PA 19114

Patsy Thomas
5603 Old Orchard Court
Rex, GA 30273

Patsy Thomas
5603 Old Orchard Court
Rex, GA 30273

Patsy Thomas
5603 Old Orchard Court
Rex, GA 30273

Patsy Thomas
5603 Old Orchard Court
Rex, GA 30273

Case 12-61259-mgd Doc 1 Filed 04/30/12 Entered 04/30/12 19:11:58 Desc Main

B22C (Official Form 22C) (Chapter 13) (12/10)

Document Page 39 of 47

Tom Thomas

In re

Case Number:

Debtor(s)

(If known)

According to the calculations required by this statement:

The applicable commitment period is 3 years.
The applicable commitment period is 5 years.
Disposable income is determined under § 1325(b)(3).
Disposable income not determined under § 1325(b)(3).

(Check the boxes as directed in Lines 17 and 23 of this statement.)

CHAPTER 13 STATEMENT OF CURRENT MONTHLY INCOME

AND CALCULATION OF COMMITMENT PERIOD AND DISPOSABLE INCOME
In addition to Schedule I and J, this statement must be completed by every individual Chapter 13 debtor, whether or not filing
jointly. Joint debtors may complete one statement only.

Part I. REPORT OF INCOME

Unmarried. Complete only Column A (“Debtor’s Income”) for Lines 2-10.

Marital/filing status. Check the box that applies and complete the balance of this part of this statement as directed.
a.
b. Married. Complete both Column A (“Debtor’s Income”) and Column B ("Spouse’s Income") for Lines 2-10.
All figures must reflect average monthly income received from all sources, derived during the
six calendar months prior to filing the bankruptcy case, ending on the last day of the month
before the filing. If the amount of monthly income varied during the six months, you must
divide the six-month total by six, and enter the result on the appropriate line.

Column A
Debtor’s
Income

Column B
Spouse’s
Income

Gross wages, salary, tips, bonuses, overtime, commissions.
Income from the operation of a business, profession or farm. Subtract Line b from Line a
and enter the difference in the appropriate column(s) of Line 3. If you operate more than one
business, profession or farm, enter aggregate numbers and provide details on an attachment.
Do not enter a number less than zero. Do not include any part of the business expenses
entered on Line b as a deduction in Part IV.

a.
b.
c.

Gross receipts
Ordinary and necessary business expenses
Business income

$
0.00
$
0.00
Subtract Line b from Line a

Rents and other real property income. Subtract Line b from Line a and enter the difference in
the appropriate column(s) of Line 4. Do not enter a number less than zero. Do not include any
part of the operating expenses entered on Line b as a deduction in Part IV.

a.
b.
c.

Gross receipts
Ordinary and necessary operating expenses
Rent and other real property income

0.00
$
0.00
$
Subtract Line b from Line a

Interest, dividends and royalties.
Pension and retirement income.
Any amounts paid by another person or entity, on a regular basis, for the household
expenses of the debtor or the debtor's dependents, including child support paid for that
purpose. Do not include alimony or separate maintenance payments or amounts paid by the
debtor’s spouse. Each regular payment should be reported in only one column; if a payment is
listed in Column A, do not report that payment in Column B.

$

1,713.00

$

1,941.00

$

$
$
$

$

0.00

$

0.00

0.00
0.00
1,116.00

$
$
$

0.00
0.00
0.00

0.00

$

0.00

1

2

3

4

5
6

7

0

.

3

e
g
n
a
h
C
X
-
F
D
P

-


0
1
1
1
0
-
X
1
0
3
-
1
3
1
2
3

-


4
7
7
-
7

.

6

.

4


.
r
e
v


,
.
c
n
I

,
e
r
a
w

t
f
o
S

e
p
o
H
w
e
N




,



2
1
0
2
-
1
9
9
1
©
2
1
0
2
y
c
t
p
u
r
k
n
a
B

Case 12-61259-mgd Doc 1 Filed 04/30/12 Entered 04/30/12 19:11:58 Desc Main

B22C (Official Form 22C) (Chapter 13) (12/10) - Cont.

Document Page 40 of 47

Unemployment compensation. Enter the amount in the appropriate column(s) of Line 8.
However, if you contend that unemployment compensation received by you or your spouse was a
benefit under the Social Security Act, do not list the amount of such compensation in Column A
or B, but instead state the amount in the space below:
Unemployment compensation claimed to be a
0.00
benefit under the Social Security Act
Unemployment compensation. Enter the amount in the appropriate column(s) of Line 8.
Income from all other sources. Specify source and amount. If necessary, list additional
sources on a separate page. Total and enter on Line 9. Do not include alimony or separate
maintenance payments paid by your spouse, but include all other payments of alimony or
separate maintenance. Do not include any benefits received under the Social Security Act or
payments received as a victim of a war crime, crime against humanity, or as a victim of
international or domestic terrorism.

Spouse $

Debtor $

0.00

a.
b.

$
$

0.00
0.00

2

$

0.00

$

0.00

0.00

2,829.00

$

$

$
$

$

0.00

1,941.00

4,770.00

8

9

10

11

12

13

0

.

3

e
g
n
a
h
C
X
-
F
D
P

-


0
1
1
1
0
-
X
1
0
3
-
1
3
1
2
3

-


4
7
7
-
7

.

6

.

4


.
r
e
v


,
.
c
n
I

,
e
r
a
w

t
f
o
S

e
p
o
H
w
e
N




,



2
1
0
2
-
1
9
9
1
©
2
1
0
2
y
c
t
p
u
r
k
n
a
B

Subtotal. Add Lines 2 thru 9 in Column A, and, if Column B is completed, add Lines 2
through 9 in Column B. Enter the total(s).
Total. If Column B has been completed, add Line 10, Column A to Line 10, Column B, and
enter the total. If Column B has not been completed, enter the amount from Line 10, Column
A.

Part II. CALCULATION OF § 1325(b)(4) COMMITMENT PERIOD

Enter the Amount from Line 11.
Marital adjustment. If you are married, but are not filing jointly with your spouse, AND if you contend that
calculation of the commitment period under § 1325(b)(4) does not require inclusion of the income of your
spouse, enter on Line 13 the amount of the income listed in Line 10, Column B that was NOT paid on a
regular basis for the household expenses of you or your dependents and specify, in the lines below, the basis
for excluding this income (such as payment of the spouse's tax liability or the spouse's support of persons
other than the debtor or the debtor's dependents) and the amount of income devoted to each purpose. If
necessary, list additional adjustments on a separate page. If the conditions for entering this adjustment do not
apply, enter zero.

Wife's payroll

a.
b.
c.

$
$
$

625.00
0.00
0.00

Total and enter on Line 13.
Subtract Line 13 from Line 12 and enter the result.

14
15 Annualized current monthly income for §1325(b)(4). Multiply the amount from Line 14 by the number
12 and enter the result.
Applicable median family income. Enter the median family income for the applicable state and household
size. (This information is available by family size at www.usdoj.gov/ust/ or from the clerk of the bankruptcy
court.)

16

a. Enter debtor’s state of residence: _______________ b. Enter debtor’s household size: __________

Georgia

2

$

4,770.00

$
$

$

625.00

4,145.00

49,740.00

$

50,712.00

Application of §1325(b)(4). Check the applicable box and proceed as directed.

The amount on Line 15 is less than the amount on Line 16. Check the box for “The applicable commitment period is
3 years” at the top of page 1 of this statement and continue with this statement.

The amount on Line 15 is more than the amount on Line 16. Check the box for “The applicable commitment period
is 5 years” at the top of page 1 of this statement and continue with this statement.

Part III. APPLICATION OF § 1325(b)(3) FOR DETERMINING DISPOSABLE INCOME
Enter the Amount from Line11.

$

4,770.00

17

18

Case 12-61259-mgd Doc 1 Filed 04/30/12 Entered 04/30/12 19:11:58 Desc Main

B22C (Official Form 22C) (Chapter 13) (12/10) - Cont.

Document Page 41 of 47

3

Marital adjustment. If you are married, but are not filing jointly with your spouse, enter on Line 19 the total
of any income listed in Line 10, Column B that was NOT paid on a regular basis for the household expenses
of the debtor or the debtor’s dependents. Specify, in the lines below, the basis for excluding the Column B
income (such as payment of the spouse's tax liability or the spouse's support of persons other than the debtor
or the debtor's dependents) and the amount of income devoted to each purpose. If necessary, list additional
adjustments on a separate page. If the conditions for entering this adjustment do not apply, enter zero.

a.
b.
c.

$
$
$

0.00
0.00
0.00

Total and enter on Line 19.
Current monthly income for §1325(b)(3). Subtract Line 19 from Line 18 and enter the result.
Annualized current monthly income for §1325(b)(3). Multiply the amount from Line 20 by the
number 12 and enter the result.
Applicable median family income. Enter the amount from Line 16.

Application of §1325(b)(3). Check the applicable box and proceed as directed.

$
$

$
$

0.00
4,770.00

57,240.00

50,712.00

The amount on Line 21 is more than the amount on Line 22. Check the box for “Disposable income is determined
under §1325(b)(3)” at the top of page 1 of this statement and complete the remaining parts of this statement.
The amount on Line 21 is not more than the amount on Line 22. Check the box for “Disposable income is not
determined under §1325(b)(3)” at the top of page 1 of this statement and continue with Part VII of this statement. Do not
complete Parts IV, V or VI.

Part IV. CALCULATION OF DEDUCTIONS FROM INCOME

Subpart A: Deductions under Standards of the Internal Revenue Service (IRS)

19

20

21

22

23

24A

24B

0

.

3

e
g
n
a
h
C
X
-
F
D
P

-


0
1
1
1
0
-
X
1
0
3
-
1
3
1
2
3

-


4
7
7
-
7

.

6

.

4


.
r
e
v


,
.
c
n
I

,
e
r
a
w

t
f
o
S

e
p
o
H
w
e
N




,



2
1
0
2
-
1
9
9
1
©
2
1
0
2
y
c
t
p
u
r
k
n
a
B

National Standards: food, apparel and services, housekeeping supplies, personal care, and
miscellaneous. Enter in line 24A the “Total” amount from IRS National Standards for Allowable Living
Expenses for the applicable number of persons. (This information is available at www.usdoj.gov/ust/ or from
the clerk of the bankruptcy court.) The applicable number of persons is the number that would currently be
allowed as exemptions on your federal income tax return, plus the number of any additional dependents
whom you support.
National Standards: health care. Enter in Line a1 below the amount from IRS National Standards for Out-
of-Pocket Health Care for persons under 65 years of age, and in Line a2 the IRS National Standards for Out-
of-Pocket Health Care for persons 65 years of age or older. (This information is available at
www.usdoj.gov/ust/ or from the clerk of the bankruptcy court.) Enter in Line b1 the applicable number of
persons who are under 65 years of age, and enter in Line b2 the applicable number of persons who are 65
years of age or older. (The applicable number of persons in each age category is the number in that category
that would currently be allowed as exemptions on your federal income tax return, plus the number of any
additional dependents whom you support.) Multiply line a1 by Line b1 to obtain a total amount for persons
under 65, and enter the result in Line c1. Multiply Line a2 by Line b2 to obtain a total amount for persons 65
and older, and enter the result in Line c2. Add Lines c1 and c2 to obtain a total health care amount, and enter
the result in Line 24B.
Persons under 65 years of age
a1. Allowance per person
b1
.
c1.

Persons 65 years of age or older
a2.
b2.
c2.

Allowance per person
Number of persons
Subtotal

Number of persons
Subtotal

144.00
0
0.00

60.00
2
120.00

25A

Local Standards: housing and utilities; non-mortgage expenses. Enter amount of the IRS Housing and
Utilities Standards; non-mortgage expenses for the applicable county and family size. (This information is
available at www.usdoj.gov/ust/ or from the clerk of the bankruptcy court.) The applicable family size
consists of the number that would currently be allowed as exemptions on your federal income tax return, plus
the number of any additional dependents whom you support.

$

0.00

$

$

120.00

0.00

Case 12-61259-mgd Doc 1 Filed 04/30/12 Entered 04/30/12 19:11:58 Desc Main

B22C (Official Form 22C) (Chapter 13) (12/10) - Cont.

Document Page 42 of 47

4

Local Standards: housing and utilities; mortgage/rent expense. Enter, in Line a below, the amount of the
IRS Housing and Utilities Standards; mortgage/rent expense for your county and family size (this information
is available at www.usdoj.gov/ust/ or from the clerk of the bankruptcy court) (the applicable family size
consists of the number that would currently be allowed as exemptions on your federal income tax return, plus
the number of any additional dependents whom you support); enter on Line b the total of the Average
Monthly Payments for any debts secured by your home, as stated in Line 47; subtract Line b from Line a and
enter the result in Line 25B. Do not enter an amount less than zero.

25B

a.

b.

c.

IRS Housing and Utilities Standards; mortgage/rental expense
Average Monthly Payment for any debts secured by your home,
if any, as stated in Line 47
Net mortgage/rental expense

$

$

0.00

0.00

Subtract Line b from Line a.

$

0.00

Local Standards: housing and utilities; adjustment. If you contend that the process set out in Lines 25A
and 25B does not accurately compute the allowance to which you are entitled under the IRS Housing and
Utilities Standards, enter any additional amount to which you contend you are entitled, and state the basis for
your contention in the space below:

26

0 1

2 or more.

Local Standards: transportation; vehicle operation/public transportation expense. You are entitled to an
expense allowance in this category regardless of whether you pay the expenses of operating a vehicle and
regardless of whether you use public transportation.
Check the number of vehicles for which you pay the operating expenses or for which the operating expenses
are included as a contribution to your household expenses in Line 7.
If you checked 0, enter on Line 27A the “Public Transportation” amount from IRS Local Standards:
Transportation. If you checked 1 or 2 or more, enter on Line 27A the “Operating Costs” amount from IRS
Local Standards: Transportation for the applicable number of vehicles in the applicable Metropolitan
Statistical Area or Census Region. (These amounts are available at www.usdoj.gov/ust/ or from the clerk of
the bankruptcy court.)
Local Standards: transportation; additional public transportation expense. If you pay the operating
expenses for a vehicle and also use public transportation, and you contend that you are entitled to an
additional deduction for your public transportation expenses, enter on Line 27B the “Public Transportation”
amount from the IRS Local Standards: Transportation. (This amount is available at www.usdoj.gov/ust/ or
from the clerk of the bankruptcy court.)
Local Standards: transportation ownership/lease expense; Vehicle 1. Check the number of vehicles for
which you claim an ownership/lease expense. (You may not claim an ownership/lease expense for more than
two vehicles.)
Enter, in Line a below, the “Ownership Costs” for “One Car” from the IRS Local Standards: Transportation
(available at www.usdoj.gov/ust/ or from the clerk of the bankruptcy court); enter in Line b the total of the
Average Monthly Payments for any debts secured by Vehicle 1, as stated in Line 47; subtract Line b from
Line a and enter the result in Line 28. Do not enter an amount less than zero.
$

1 2 or more.

0.00

0

.

3

e
g
n
a
h
C
X
-
F
D
P

-


0
1
1
1
0
-
X
1
0
3
-
1
3
1
2
3

-


4
7
7
-
7

.

6

.

4


.
r
e
v


,
.
c
n
I

,
e
r
a
w

t
f
o
S

e
p
o
H
w
e
N




,



2
1
0
2
-
1
9
9
1
©
2
1
0
2
y
c
t
p
u
r
k
n
a
B

27A

27B

28

$

0.00

$

$

0.00

0.00

a.

b.
c.

IRS Transportation Standards, Ownership Costs
Average Monthly Payment for any debts secured by Vehicle 1,
as stated in Line 47
Net ownership/lease expense for Vehicle 1

$
Subtract Line b from Line a.

0.00

$

0.00

Case 12-61259-mgd Doc 1 Filed 04/30/12 Entered 04/30/12 19:11:58 Desc Main

B22C (Official Form 22C) (Chapter 13) (12/10) - Cont.

Document Page 43 of 47

Local Standards: transportation ownership/lease expense; Vehicle 2. Complete this Line only if you
checked the “2 or more” Box in Line 28.
Enter, in Line a below, the “Ownership Costs” for “One Car” from the IRS Local Standards: Transportation
(available at www.usdoj.gov/ust/ or from the clerk of the bankruptcy court); enter in Line b the total of the
Average Monthly Payments for any debts secured by Vehicle 2, as stated in Line 47; subtract Line b from
Line a and enter the result in Line 29. Do not enter an amount less than zero.
$

a.

0.00

IRS Transportation Standards, Ownership Costs
Average Monthly Payment for any debts secured by Vehicle 2,
as stated in Line 47
Net ownership/lease expense for Vehicle 2

b.
c.

$
0.00
Subtract Line b from Line a.

Other Necessary Expenses: taxes. Enter the total average monthly expense that you actually incur for all for
all federal, state and local taxes, other than real estate and sales taxes, such as income taxes, self-employment
taxes, social security taxes, and Medicare taxes. Do not include real estate or sales taxes.

Other Necessary Expenses: involuntary deductions for employment. Enter the total average monthly
deductions that are required for your employment, such as mandatory retirement contributions, union dues,
and uniform costs. Do not include discretionary amounts, such as voluntary 401(k) contributions.
Other Necessary Expenses: life insurance. Enter total average monthly premiums that you actually pay for
term life insurance for yourself. Do not include premiums for insurance on your dependents, for whole life
or for any other form of insurance.
Other Necessary Expenses: court-ordered payments. Enter the total monthly amount that you are required
to pay pursuant to the order of a court or administrative agency, such as spousal or child support payments. Do
not include payments on past due support obligations included in Line 49.
Other Necessary Expenses: education for employment or for a physically or mentally challenged child.
Enter the total monthly amount that you actually expend for education that is a condition of employment and
for education that is required for a physically or mentally challenged dependent child for whom no public
education providing similar services is available.
Other Necessary Expenses: childcare. Enter the total average monthly amount that you actually expend on
childcare—such as baby-sitting, day care, nursery and preschool. Do not include other educational
payments.
Other Necessary Expenses: health care. Enter the total average monthly amount that you actually expend
on health care that is required for the health and welfare of yourself or your dependents, that is not reimbursed
by insurance or paid by a health savings account, and that is in excess of the amount entered in Line 24B. Do
not include payments for health insurance or health savings accounts listed in Line 39.

Other Necessary Expenses: telecommunication services. Enter the total average monthly amount that you
actually pay for telecommunications services other than your basic home telephone and cell phone service –
such as pagers, call waiting, caller id, special long distance, or internet service—to the extent necessary for
your health and welfare or that of your dependents. Do not include any amount previously deducted.

Total Expenses Allowed under IRS Standards. Enter the total of Lines 24 through 37.

Subpart B: Additional Living Expense Deductions

Note: Do not include any expenses that you have listed in Lines 24-37

$

$

$

$

$

$

$

$

$

$

29

30

31

32

33

34

35

36

37

38

0

.

3

e
g
n
a
h
C
X
-
F
D
P

-


0
1
1
1
0
-
X
1
0
3
-
1
3
1
2
3

-


4
7
7
-
7

.

6

.

4


.
r
e
v


,
.
c
n
I

,
e
r
a
w

t
f
o
S

e
p
o
H
w
e
N




,



2
1
0
2
-
1
9
9
1
©
2
1
0
2
y
c
t
p
u
r
k
n
a
B

5

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

120.00

Case 12-61259-mgd Doc 1 Filed 04/30/12 Entered 04/30/12 19:11:58 Desc Main

B22C (Official Form 22C) (Chapter 13) (12/10) - Cont.

Document Page 44 of 47

Health Insurance, Disability Insurance, and Health Savings Account Expenses. List the monthly
expenses in the categories set out in lines a-c below that are reasonably necessary for yourself, your spouse, or
your dependents.

Health Insurance
Disability Insurance
Health Savings Account

a.
b.
c.

$

$
$
$

0.00
0.00
0.00

39

40

41

42

43

44

45

46

0

.

3

e
g
n
a
h
C
X
-
F
D
P

-


0
1
1
1
0
-
X
1
0
3
-
1
3
1
2
3

-


4
7
7
-
7

.

6

.

4


.
r
e
v


,
.
c
n
I

,
e
r
a
w

t
f
o
S

e
p
o
H
w
e
N




,



2
1
0
2
-
1
9
9
1
©
2
1
0
2
y
c
t
p
u
r
k
n
a
B

Total and enter on Line 39
If you do not actually expend this total amount, state your actual total average monthly expenditures in the
space below:

0.00

Continued contributions to the care of household or family members. Enter the total average actual
monthly expenses that you will continue to pay for the reasonable and necessary care and support of an
elderly, chronically ill, or disabled member of your household or member of your immediate family who is
unable to pay for such expenses. Do not include payments listed in Line 34.
Protection against family violence. Enter the total average reasonably necessary monthly expenses that you
actually incur to maintain the safety of your family under the Family Violence Prevention and Services Act or
other applicable federal law. The nature of these expenses is required to be kept confidential by the court.
Home energy costs. Enter the total average monthly amount, in excess of the allowance specified by IRS Local
Standards for Housing and Utilities that you actually expend for home energy costs. You must provide your
case trustee with documentation of your actual expenses, and you must demonstrate that the additional
amount claimed is reasonable and necessary.
Education expenses for dependent children under18. Enter the total average monthly expenses that you
actually incur, not to exceed $147.92* per child, for attendance at a private or public elementary or secondary
school by your dependent children less than 18 years of age. You must provide your case trustee with
documentation of your actual expenses, and you must explain why the amount claimed is reasonable
and necessary and not already accounted for in the IRS Standards.
Additional food and clothing expense. Enter the total average monthly amount by which your food and
clothing expenses exceed the combined allowances for food and clothing (apparel and services) in the IRS
National Standards, not to exceed 5% of those combined allowances. (This information is available at
www.usdoj.gov/ust/ or from the clerk of the bankruptcy court.) You must demonstrate that the additional
amount claimed is reasonable and necessary.
Charitable contributions. Enter the amount reasonably necessary for you to expend each month on
charitable contributions in the form of cash or financial instruments to a charitable organization as defined in
26 U.S.C. § 170(c)(1)-(2). Do not include any amount in excess of 15% of your gross monthly income.

Total Additional Expense Deductions under § 707(b). Enter the total of Lines 39 through 45.

Subpart C: Deductions for Debt Payment

Future payments on secured claims. For each of your debts that is secured by an interest in property that
you own, list the name of creditor, identify the property securing the debt, and state the Average Monthly
Payment, and check whether the payment includes taxes and insurance. The Average Monthly Payment is the
total of all amounts scheduled as contractually due to each Secured Creditor in the 60 months following the
filing of the bankruptcy case, divided by 60. If necessary, list additional entries on a separate page. Enter the
total of the Average Monthly Payments on Line 47.

$

$

$

$

$

$

$
$

6

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

47

Name of Creditor

Property Securing the Debt

a.
b.
c.

Average
Monthly
Payment

Does payment
include taxes or
insurance?

0.00
$
0.00
$
0.00
$
Total: Add Lines
a, b and c

yes no
yes no
yes no

$

0.00

Case 12-61259-mgd Doc 1 Filed 04/30/12 Entered 04/30/12 19:11:58 Desc Main

B22C (Official Form 22C) (Chapter 13) (12/10) - Cont.

Document Page 45 of 47

7

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

0.00

$

$

$

$

$

$

$

$

$

Other payments on secured claims. If any of debts listed in Line 47 are secured by your primary residence,
a motor vehicle, or other property necessary for your support or the support of your dependents, you may
include in your deduction 1/60th of any amount (the “cure amount”) that you must pay the creditor in addition
to the payments listed in Line 47, in order to maintain possession of the property. The cure amount would
include any sums in default that must be paid in order to avoid repossession or foreclosure. List and total any
such amounts in the following chart. If necessary, list additional entries on a separate page.

Name of Creditor

Property Securing the Debt

a.
b.
c.

1/60th of the Cure Amount
0.00
$
0.00
$
0.00
$
Total: Add Lines a, b and c

Payments on prepetition priority claims. Enter the total amount, divided by 60, of all priority claims, such as
priority tax, child support and alimony claims, for which you were liable at the time of your bankruptcy filing.
Do not include current obligations, such as those set out in Line 33.
Chapter 13 administrative expenses. Multiply the amount in Line a by the amount in Line b, and enter the
resulting administrative expense.
a.

$

0.00

Projected average monthly Chapter 13 plan payment.
Current multiplier for your district as determined under
schedules issued by the Executive Office for United States
Trustees. (This information is available at www.usdoj.gov/ust/
or from the clerk of the bankruptcy court.)
Average monthly administrative expense of Chapter 13 case

b.

c.

x
Total: Multiply Lines a and b

5.2 %

48

48

49

50

51 Total Deductions for Debt Payment. Enter the total of Lines 47 through 50.

52 Total of all deductions from income. Enter the total of Lines 38, 46, and 51.

Subpart D: Total Deductions from Income

Part V. DETERMINATION OF DISPOSABLE INCOME UNDER § 1325(b)(2)

53 Total current monthly income. Enter the amount from Line 20.

Support income. Enter the monthly average of any child support payments, foster care payments, or
disability payments for a dependent child, reported in Part I, that you received in accordance with applicable
nonbankruptcy law, to the extent reasonably necessary to be expended for such child.
Qualified retirement deductions. Enter the monthly total of (a) all amounts withheld by your employer from
wages as contributions for qualified retirement plans, as specified in § 541(b)(7) and (b) all required
repayments of loans from retirement plans, as specified in § 362(b)(19).

54

55

56 Total of all deductions allowed under § 707(b)(2). Enter the amount from Line 52.

Deduction for special circumstances. If there are special circumstances that justify additional expenses for
which there is no reasonable alternative, describe the special circumstances and the resulting expenses in lines
a-c below. If necessary, list additional entries on a separate page. Total the expenses and enter the total in
Line 57. You must provide your case trustee with documentation of theses expenses and you must
provide a detailed explanation of the special circumstances that make such expenses necessary and
reasonable.

0

.

3

e
g
n
a
h
C
X
-
F
D
P

-


0
1
1
1
0
-
X
1
0
3
-
1
3
1
2
3

-


4
7
7
-
7

.

6

.

4


.
r
e
v


,
.
c
n
I

,
e
r
a
w

t
f
o
S

e
p
o
H
w
e
N




,



2
1
0
2
-
1
9
9
1
©
2
1
0
2
y
c
t
p
u
r
k
n
a
B

Nature of special circumstances

57

a.
b.
c.

Amount of expense

$
$
$
Total: Add Lines a, b and c

$

0.00

Case 12-61259-mgd Doc 1 Filed 04/30/12 Entered 04/30/12 19:11:58 Desc Main

B22C (Official Form 22C) (Chapter 13) (12/10) - Cont.

Document Page 46 of 47

58 Total adjustments to determine disposable income. Add the amounts on Lines 54, 55, 56 and 57 and enter

the result.

59 Monthly Disposable Income Under § 1325(b)(2). Subtract Line 58 from Line 53 and enter the result.

Part VI: ADDITIONAL EXPENSE CLAIMS

8

0.00

0.00

$

$

Other Expenses. List and describe any monthly expenses, not otherwise stated in this form, that are required for the health
and welfare of you and your family and that you contend should be an additional deduction from your current monthly income
under § 707(b)(2)(A)(ii)(I). If necessary, list additional sources on a separate page. All figures should reflect your average
monthly expense for each item. Total the expenses.

60

a.
b.
c.

Expense Description

Monthly Amount

$
$
$

0.00
0.00
0.00
0.00

Total: Add Lines a, b and c

Part VII: VERIFICATION

I declare under penalty of perjury that the information provided in this statement is true and correct. (If this a joint case,
both debtors must sign.)

61

Date:

4-30-12

Date:

4-30-12

Signature:

Signature:

/s/ Tom Thomas

(Debtor)

(Joint Debtor, if any)

0

.

3

e
g
n
a
h
C
X
-
F
D
P

-


0
1
1
1
0
-
X
1
0
3
-
1
3
1
2
3

-


4
7
7
-
7

.

6

.

4


.
r
e
v


,
.
c
n
I

,
e
r
a
w

t
f
o
S

e
p
o
H
w
e
N




,



2
1
0
2
-
1
9
9
1
©
2
1
0
2
y
c
t
p
u
r
k
n
a
B

Case 12-61259-mgd Doc 1 Filed 04/30/12 Entered 04/30/12 19:11:58 Desc Main

Document Page 47 of 47

Income Month 1

Gross wages, salary, tips...
Income from business...
Rents and real property income...
Interest, dividends...
Pension, retirement...
Contributions to HH Exp...
Unemployment...
Other Income...

Income Month 3

Gross wages, salary, tips...
Income from business...
Rents and real property income...
Interest, dividends...
Pension, retirement...
Contributions to HH Exp...
Unemployment...
Other Income...

Income Month 5

Gross wages, salary, tips...
Income from business...
Rents and real property income...
Interest, dividends...
Pension, retirement...
Contributions to HH Exp...
Unemployment...
Other Income...

Form 22 Continuation Sheet
Income Month 2

1,713.00
0.00
0.00
0.00
1,116.00
0.00
0.00
0.00

1,713.00
0.00
0.00
0.00
1,116.00
0.00
0.00
0.00

1,713.00
0.00
0.00
0.00
1,116.00
0.00
0.00
0.00

1,941.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

1,941.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

1,941.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

Gross wages, salary, tips...
Income from business...
Rents and real property income...
Interest, dividends...
Pension, retirement...
Contributions to HH Exp...
Unemployment...
Other Income...

Income Month 4

Gross wages, salary, tips...
Income from business...
Rents and real property income...
Interest, dividends...
Pension, retirement...
Contributions to HH Exp...
Unemployment...
Other Income...

Income Month 6

Gross wages, salary, tips...
Income from business...
Rents and real property income...
Interest, dividends...
Pension, retirement...
Contributions to HH Exp...
Unemployment...
Other Income...

Additional Items as Designated, if any

1,713.00
0.00
0.00
0.00
1,116.00
0.00
0.00
0.00

1,713.00
0.00
0.00
0.00
1,116.00
0.00
0.00
0.00

1,713.00
0.00
0.00
0.00
1,116.00
0.00
0.00
0.00

1,941.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

1,941.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

1,941.00
0.00
0.00
0.00
0.00
0.00
0.00
0.00

0

.

3

e
g
n
a
h
C
X
-
F
D
P

-


0
1
1
1
0
-
X
1
0
3
-
1
3
1
2
3

-


4
7
7
-
7

.

6

.

4


.
r
e
v


,
.
c
n
I

,
e
r
a
w

t
f
o
S

e
p
o
H
w
e
N




,



2
1
0
2
-
1
9
9
1
©
2
1
0
2
y
c
t
p
u
r
k
n
a
B

Remarks